Antonio Sueiro

Prognostic Significance of Deep Vein Thrombosis in Patients Presenting with Acute Symptomatic Pulmonary Embolism

RATIONALE Concomitant deep vein thrombosis (DVT) in patients with acute pulmonary embolism (PE) has an uncertain prognostic significance. OBJECTIVES In a cohort of patients with PE, this study compared the risk of death in those with and those without concomitant DVT. METHODS We conducted a prospective cohort study of outpatients diagnosed with a first episode of acute symptomatic PE. Patients underwent bilateral lower extremity venous compression ultrasonography to assess for concomitant DVT. MEASUREMENTS AND MAIN RESULTS The primary study outcome, all-cause mortality, and the secondary outcome of PE-specific mortality were assessed during the 3 months of follow-up after PE diagnosis. Multivariate Cox proportional hazards regression was done to adjust for significant covariates. Of 707 patients diagnosed with PE, 51.2% (362 of 707) had concomitant DVT and 10.9% (77 of 707) died during follow-up. Patients with concomitant DVT had an increased all-cause mortality (adjusted hazard ratio [HR], 2.05; 95% confidence interval [CI], 1.24 to 3.38; P = 0.005) and PE-specific mortality (adjusted HR, 4.25; 95% CI, 1.61 to 11.25; P = 0.04) compared with those without concomitant DVT. In an external validation cohort of 4,476 patients with acute PE enrolled in the international multicenter RIETE Registry, concomitant DVT remained a significant predictor of all-cause (adjusted HR, 1.66; 95% CI, 1.28 to 2.15; P < 0.001) and PE-specific mortality (adjusted HR, 2.01; 95% CI, 1.18 to 3.44; P = 0.01). CONCLUSIONS In patients with a first episode of acute symptomatic PE, the presence of concomitant DVT is an independent predictor of death in the ensuing 3 months after diagnosis. Assessment of the thrombotic burden should assist with risk stratification of patients with acute PE.

The risk of recurrent venous thromboembolism in patients with unprovoked symptomatic deep vein thrombosis and asymptomatic pulmonary embolism

Patients with a first episode of symptomatic pulmonary embolism (PE) have a higher risk of recurrent venous thromboembolism (VTE) than patients with a first episode of proximal lower extremity deep vein thrombosis (DVT). Patients with symptomatic DVT and silent PE may have a different risk of VTE recurrence than patients that have symptomatic DVT without PE. Therefore, it was the aim of this prospective cohort study to compare the risk of recurrent symptomatic VTE in patients with proximal lower extremity DVT and silent PE to the risk in patients that only have proximal lower extremity DVT. Ninety-one consecutive outpatients presenting to the emergency department of a university hospital subsequently hospitalised with a first episode of unprovoked symptomatic proximal lower extremity DVT, and without new pulmonary symptoms were included. Standard initial treatment consisted of intravenous unfractionated heparin or subcutaneous low-molecular-weight heparin for 5-7 days, overlapped with oral vitamin-K antagonist therapy, with long-term oral vitamin-K antagonist therapy (goal INR 2.5 [2.0-3.0]). Study endpoints were: symptomatic recurrent DVT, new PE, and recurrent PE, evaluated by standard objective testing. At enrollment, 28 of 91 (31%) patients with DVT had silent PE. In the patients with DVT and silent PE, there were 3 VTE recurrences during 20 person-years of follow-up, while there were no VTE recurrences during 61 person-years of follow- up in the patients with isolated DVT. The Kaplan-Meier estimated VTE recurrence rate at 1 year after the diagnosis of DVT was 11% (95% CI: 2-28%) for patients with symptomatic DVT and silent PE, compared to 0% in patients with isolated symptomatic DVT (p=0.0045). In patients with a first episode of unprovoked symptomatic acute proximal lower extremity DVT, the risk of recurrent VTE was significantly higher in those with silent PE compared to those without PE.

Incidence of Symptomatic and Asymptomatic Chronic Thromboembolic Pulmonary Hypertension

Abstract Introduction and objectives To assess the incidence of long-term symptomatic and asymptomatic chronic thromboembolic pulmonary hypertension (CTPH) in a cohort of patients with acute symptomatic pulmonary embolism (PE), and the potential risk factors for its diagnosis. Methods We conducted a prospective, long-term, follow-up study in 110 consecutive patients with an acute episode of pulmonary embolism (PE). All patients underwent transthoracic echocardiography (TTE) two years after the diagnosis of PE was made. If systolic pulmonary artery pressure exceeded 40 mm Hg and there was evidence of residual PE either by ventilation-perfusion or CT scan, patients underwent right heart catheterisation to confirm the diagnosis. In asymptomatic patients, right heart catheterisation was performed if a repeated TTE still demonstrated persistent pulmonary hypertension six months after the first. Results CTPH was diagnosed in 10 cases (6 patients during follow-up, and 4 at the end of the study) of the 110 patients (9.1%; 95% confidence interval [CI], 3.7-14.5). All patients had symptoms related to the disease according to a structured questionnaire. In the multivariate regression analysis, only concomitant age (relative risk [RR] 1.2 per age; 95% CI, 1.0-1.3; P=.03) and previous PE (RR 5.7; IC 95%, 1.5-22.0; P=.01) were independent predictors of CTPH. Conclusions The cumulative incidence of CTPH appears to be higher than previously reported. All patients had symptoms related to the disease.

Pleural Fluid Parameters Identifying Complicated Parapneumonic Effusions

Background: Controversy exists regarding the clinical utility of pleural fluid parameters as prognosticators of complicated parapneumonic effusions that require drainage. Objectives: The purpose of this prospective study is to further assess the utility of these parameters in the management of a larger series of parapneumonic effusions and to determine appropriate binary decision thresholds. Methods: We studied 238 consecutive patients with parapneumonic effusions who underwent diagnostic thoracentesis. Results: We found that pleural fluid pH had the highest diagnostic accuracy (area under the curve, AUC: 0.928; 95% confidence interval, CI: 0.894–0.963) compared with pleural fluid glucose (AUC: 0.835; 95% CI: 0.773–0.897), LDH (AUC: 0.824; 95% CI: 0.761–0.887) or pleural fluid volume (AUC: 0.706; 95% CI: 0.634–0.777). The optimal binary decision threshold for pleural fluid pH identifying complicated effusions requiring drainage was 7.15. Binary, multilevel and continuous likelihood ratios (LRs) for pH were calculated to estimate the likelihood of complication of the pleural effusion. Values for the LRs were compared for each of the three strategies, and relative clinical and statistical significances were assessed. Binary LRs provided significantly less information than continuous strategies. Conclusion: The pH has the highest diagnostic accuracy for identifying complicated parapneumonic pleural effusions. The binary decision threshold determining the need for chest drainage is 7.15 in our patient series. We recommend continuous LRs to estimate the post-test probability of the complication as they provide the most information compared with binary LRs. Our results do not support the use of pleural fluid LDH as independent predictor of complicated parapneumonic effusions.

Incidencia de hipertensión pulmonar tromboembólica crónica sintomática y asintomática

INTRODUCTION AND OBJECTIVES To assess the incidence of long-term symptomatic and asymptomatic chronic thromboembolic pulmonary hypertension (CTEPH) in a cohort of patients with acute symptomatic pulmonary embolism (PE), and the potential risk factors for its diagnosis. METHODS We conducted a prospective, long-term, follow-up study in 110 consecutive patients with an acute episode of pulmonary embolism (PE). All patients underwent transthoracic echocardiography (TTE) two years after the diagnosis of PE was made. If systolic pulmonary artery pressure exceeded 40 mm Hg and there was evidence of residual PE either by ventilation-perfusion or CT scan, patients underwent right heart catheterisation to confirm the diagnosis. In asymptomatic patients, right heart catheterisation was performed if a repeated TTE still demonstrated persistent pulmonary hypertension six months after the first. RESULTS CTEPH was diagnosed in 10 (6 patients during follow-up, and 4 at the end of the study) of the 110 patients (9.1%; 95% confidence interval [CI], 3.7 to 14.5%). All patients showed symptoms related to the disease according to a structured questionnaire. In the multivariate regression analysis, only concomitant age (relative risk [RR] 1.2 per age; 95% CI, 1.0 to 1.3; P=0.03) and previous PE (RR 5.7; IC 95%, 1.5 a 22.0; P=0.01) were independent predictors of CTEPH. CONCLUSIONS CTEPH cumulative incidence appears to be higher than previously reported. All patients had symptoms related to the disease.

Prognostic Value of Electrocardiographic Findings in Hemodynamically Stable Patients With Acute Symptomatic Pulmonary Embolism

INTRODUCTION AND OBJECTIVES The aim of this study was to determine the prognostic value of electrocardiography in hemodynamically stable patients with a diagnosis of acute symptomatic pulmonary embolism (PE). METHODS This prospective study included all hemodynamically stable outpatients who were diagnosed with PE at a university hospital. The electrocardiographic abnormalities investigated were: a) sinus tachycardia (>100 beats/min); b) ST-segment or T-wave abnormalities; c) right bundle branch block; d) an S1Q3T3 pattern, and e) recent-onset atrial arrhythmia. RESULTS The study included 644 patients. Overall, 5% of those with an ECG abnormality died due to PE in the 15 days after diagnosis compared with 2% of those with normal ECG findings (relative risk [RR]=2.4; 95% confidence interval [CI], 1-5,8; P=.05). Multivariate analysis showed that sinus tachycardia was associated with a 2.2-fold increased risk of death due to all causes in the month after PE diagnosis. After adjusting for age, a history of cancer, immobility, ECG abnormalities, and sinus tachycardia, the presence of recent-onset atrial arrhythmia was significantly associated with death due to PE in the first 15 days (RR=2.8; 95% CI, 1-8.3; P=.05). The negative predictive value of atrial arrhythmia for 15-day PE-related mortality was 97%, while the negative likelihood ratio was 0.79. CONCLUSIONS In hemodynamically stable patients with acute symptomatic PE, the presence of sinus tachycardia and atrial arrhythmia were independent predictors of a poor prognosis. However, the usefulness of these factors for stratifying risk in PE patients is limited.

Valor pronóstico de los hallazgos electrocardiográficos en pacientes estables hemodinámicamente con tromboembolia de pulmón aguda sintomática

Introduccion y objetivos El objetivo de este estudio es evaluar el valor pronostico del electrocardiograma (ECG) en pacientes estables hemodinamicamente con diagnostico de tromboembolia pulmonar (TEP) aguda sintomatica. Metodos Se incluyo de forma prospectiva a todos los pacientes ambulatorios estables hemodinamicamente diagnosticados de TEP aguda sintomatica en un hospital universitario terciario. Las anomalias electrocardiograficas consideradas fueron: a) taquicardia sinusal (> 100 lat/min); b) alteraciones del segmento ST o de la onda T; c) bloqueo de la rama derecha del haz de His (BRDHH); d) patron S1Q3T3, y e) arritmias auriculares de reciente comienzo. Resultados Se incluyo a 644 pacientes en el estudio. Un 5% de los pacientes con ECG anormal fallecieron por TEP en los 15 dias posteriores al diagnostico, comparado con un 2% de los pacientes con ECG normal (razon de riesgo [RR] = 2,4; intervalo de confianza [IC] del 95%, 1-5,8; p = 0,05). En el analisis multivariable, la taquicardia sinusal multiplico por 2,2 el riesgo de muerte por todas las causas en el mes posterior al diagnostico de TEP. Tras ajustar por edad, antecedentes de cancer, inmovilizacion, un ECG alterado y la presencia de taquicardia sinusal, las arritmias auriculares de reciente diagnostico se asociaron de forma significativa a la muerte por TEP durante los primeros 15 dias (RR = 2,8; IC del 95%, 1–8,3; p = 0,05). Las arritmias auriculares mostraron un alto valor predictivo negativo de muerte por TEP a los 15 dias (97%), pero la razon de probabilidad negativa fue 0,79. Conclusiones En pacientes estables hemodinamicamente con TEP aguda sintomatica, la taquicardia sinusal y las arritmias auriculares son predictoras independientes de mal pronostico. Sin embargo, su utilidad en la estratificacion pronostica de estos pacientes es limitada.

Aparición de episodios tromboembólicos en pacientes con angiotomografía axial computarizada simple negativa. Estudio retrospectivo de 165 pacientes

Objetivo Determinar el rendimiento de la angiotomografia axial computarizada (angio-TAC) de torax en el diagnostico de exclusion de la tromboembolia pulmonar (TEP) y comprobar la observancia de los protocolos diagnosticos de enfermedad tromboembolica. Pacientes y metodos Realizamos un estudio retrospectivo de los pacientes a quienes se realizo una angio-TAC de torax por sospecha de TEP durante el ano 2004. Se realizo un seguimiento de 3 meses en todos ellos. Se determino el porcentaje de pacientes diagnosticados de un episodio tromboembolico por un metodo objetivo durante el periodo de seguimiento. Se analizo el porcentaje de pacientes con angio-TAC negativa a quienes se realizo alguna prueba diagnostica adicional (ecografia de miembros inferiores y/o gammagrafia de ventilacion-perfusion pulmonar). Resultados Durante el ano 2004 se realizaron 165 angio-TAC de torax por sospecha de TEP. Se excluyo a 4 pacientes con indicacion de anticoagulacion cronica y a otros 2 con pronostico de vida inferior a 3 meses. De los 159 pacientes restantes, en 60 la angio-TAC se interpreto como de alta probabilidad para TEP (prevalencia del 38%). Entre los 99 pacientes con angio-TAC negativa, se produjo un episodio tromboembolico objetivamente confirmado en 35 de ellos (sensibilidad del 63%; intervalo de confianza del 95%, 53-73%). En el 46% de los pacientes no se realizo ninguna prueba diagnostica adicional. Conclusiones En nuestro medio la angio-TAC helicoidal no multidetectora negativa es insuficiente para el diagnostico de exclusion de la TEP. La observancia de los protocolos diagnosticos internacionalmente aceptados dista de ser optima.

Thromboembolic Events in Patients After a Negative Computed Tomography Pulmonary Angiogram: a Retrospective Study of 165 Patients

OBJECTIVE To determine the value of computed tomography (CT) angiography of the chest as a diagnostic test to exclude pulmonary embolism and to assess compliance with diagnostic protocols for thromboembolic disease. PATIENTS AND METHODS We retrospectively studied patients who underwent CT angiography of the chest because of suspected pulmonary embolism in 2004. All the patients were followed for 3 months. The percentage of patients diagnosed with a thromboembolic event based on an objective test during the follow-up period was determined. We analyzed the percentage of patients with a negative CT angiogram on whom additional diagnostic tests (ultrasound of the lower limbs and/or ventilation-perfusion lung scintigraphy) were performed. RESULTS One hundred sixty-five patients underwent CT angiography of the chest because of suspected pulmonary embolism in 2004. Four of the patients were excluded from the study because they were on chronic anticoagulation therapy and a further 2 were excluded because they had a life expectancy of under 3 months. Of the remaining 159 patients, 60 had CT angiograms that were interpreted as high probability for pulmonary embolism (prevalence of 38%). Thirty-nine of the 99 patients with a negative CT angiogram experienced an objectively confirmed thromboembolic event (63% sensitivity; 95% confidence interval, 53%-73%). Other diagnostic tests were not performed in 46% of the cases. CONCLUSIONS In our setting, a negative single-detector helical CT angiogram was not sensitive enough to exclude the diagnosis of pulmonary embolism. Furthermore, compliance with internationally accepted diagnostic protocols was far from optimal.

Association of anaemia and mortality in patients with acute pulmonary embolism

This study aimed to evaluate the relationship between anaemia and pulmonary embolism (PE) prognosis. We analysed a cohort of 764 patients with acute PE referred to a single center for diagnosis and management. Patients were divided into groups by quartiles of haemoglobin (Hb): Hb < 11.7 g/dl; Hb 11.7 to 12.9 g/dl; Hb 13.0 to 14.1 g/dl; Hb > 14.1 g/dl. Patients had a mean Hb of 12.9 g/dl, and values ranged from to 4.3 to 19.5 g/dl. Lower Hb was associated with recent bleeding, an impaired haemodynamic profile and higher creatinine. Patients in the lower Hb quartiles more commonly had female gender (p < 0.001), a diagnosis of cancer (p < 0.001), and an indication for an inferior vena cava (IVC) filter (p < 0.002), compared to patients in the higher Hb quartiles. Patients in higher Hb quartiles had higher survival at three months (75%, 86%, 90% and 91% for lowest to highest quartiles, respectively). On multivariate analysis, adjusting for known PE prognostic factors, low Hb proved to be an independent predictor of mortality (hazard ratio [HR] 1.16, 95% confidence interval [CI] 1.05 to 1.28 for each decrease of 1 g/dl). Hb level remained an independent predictor of all-cause mortality when cancer patients were excluded from the analysis (adjusted HR 0.81; 95% CI, 0.66 to 0.99; p = 0.04). Moreover, patients with anaemia showed a higher risk of fatal PE (unadjusted HR 1.19, 95% CI 1.04 to 1.37). In conclusion, in patients with acute symptomatic PE, anaemia severity is associated with worsened survival.