Takahiro Yazu

Prognostic significance of early diagnosis in acute pulmonary thromboembolism with circulatory failure

Abstract. Despite the advances in our understanding of venous thromboembolic disease, the prevalence of pulmonary thromboembolism (PTE) at autopsy has not changed over 3 decades. When patients survive long enough to have a diagnosis of massive PTE and start receiving treatment, the outlook is considered to be moderately good. However, the diagnosis is often difficult to obtain and is frequently missed. We hypothesize that mortality of acute PTE is reduced by early diagnosis. Eighty-five patients with acute PTE with circulatory failure who survived 1 h after the onset were divided into two groups: the early Dx group consisted of the patients whose disease was diagnosed as acute PTE within 24 h of the onset, and the Late Dx group included patients whose disease was not diagnosed within 24 h of onset, or died without clinical diagnosis between 1 and 24 h after the onset. Overall mortality was significantly low in the Early Dx group compared with that of the Late Dx group (21.6% vs 67.6%, P < 0.0001). Multiple logistic regression analysis demonstrated that a reduction in in-hospital mortality was associated with early diagnosis (odds ratio for in-hospital death, 0.094; 95% confidence interval, 0.03–0.33). The results of our study suggested that early diagnosis might favorably affect the in-hospital clinical outcome of hemodynamically unstable patients with acute PTE.

Pulmonary embolism is an important cause of death in young adults.

BACKGROUND Population-based analysis shows that deaths from pulmonary embolism (PE) are increasing in the older age groups, but it is unclear to what degree PE contributes to death in different ages and gender. METHODS AND RESULTS Potential contribution factors for all PE and for critical PE (in which PE was the primary cause of death or the main diagnosis) were examined in 396,982 autopsy cases. For all PE, odds ratio (OR) in males was 0.61 (95% confidence interval (CI) 0.59-0.64, p<0.0001), compared with that in females. ORs were 1.10 (95% CI 1.05-1.14, p<0.0001) in 1991-1994 and 1.19 (95% CI 1.14-1.25, p<0.0001) in 1995-1998, compared with those in 1987-1990. ORs for ages 0-9 and 40+ were significantly low compared with that for ages 20-39. For critical PE, similar results were obtained. Pregnancy and/or delivery were found in 38.5% in cases of critical PE in females aged 20-39. CONCLUSION Compared with other age groups, PE contributed more to deaths in those aged 20-39 years. In recent years, deaths from PE have been slightly but significantly increasing. The incidence of clinically diagnosed critical PE also has been increasing.

Improving Drug Adherence Using Fixed Combinations Caused Beneficial Treatment Outcomes and Decreased Health-Care Costs in Patients with Hypertension

We enrolled 196 patients with hypertension who were already being treated with free-drug combinations of angiotensin-II receptor blocker (ARB) and amlodipine. The free-drug combinations of ARB and amlodipine were replaced with the same dose of the fixed-dose combinations. The average home blood pressure (BP) in all patients receiving fixed-dose combinations was significantly lower than those receiving free-drug combinations (131 ± 10/75 ± 8 vs. 136 ± 11/77 ± 9 mm Hg, P < .01) accompanied with increasing drug adherence. After lowering BP by fixed-dose combinations, the costs for medications decreased by 31% over the 3 months.

An autopsy case of intracranial hemorrhage during tissue plasminogen activator infusion

SummaryWe describe an autopsy case of severe intracranial hemorrhage which occurred during the infusion of tissue plasminogen activator (t-PA) for acute myocardial infarction. A 75-year-old man was admitted with substernal chest pain of 3-h duration and elctro-cardiographic changes consistent with an acute inferior myocardial infarction. Physical examination was unremarkable, except for an initial blood pressure reading of 160/96 mmHg. The patient received 3,000 IU intravenous heparin followed by a 2.4 × 106 IU bolus dose of tissue plasminogen activator (t-PA) (Alteplase). This was followed by a drip infusion of 21.6 × 106 IU of t-PA over 1 h (total dose 41 mg). Thirty minutes after the infusion of t-PA was initiated, the patient suddenly lost consciousness and began to have violent convulsions, followed by cardiac arrest. Autopsy revealed massive hemorrhage in the bilateral cerebrum and brain stem. To our knowledge, this is the first case of sudden death during t-PA infusion therapy.

Pulmonary Magnetic Resonance Angiography for Detection of Pulmonary Embolism

The diagnosis of pulmonary embolism may be difficult, because no reliable noninvasive imaging method is available. An accurate, noninvasive diagnostic modality is highly desirable. The purpose of this study was to evaluate the accuracy of magnetic resonance (MR) angiography in the noninvasive diagnosis of pulmonary embolism. Eighteen patients in whom the presence of pulmonary emboli was suspected underwent both conventional pulmonary angiography and MR angiography. The sensitivity and specificity of MR angiography to the level of lobar arteries were 100% and 85%, respectively, and to the level of segmental arteries, 94% and 78%, respectively. A single sectional image of MR angiography can depict thromboemboli in the proximal portion of the pulmonary arteries more definitively than conventional pulmonary angiography or a maximum-intensity-pixel projection image of MR angiography. MR angiography can reliably depict pulmonary thromboemboli down to the segmental level.