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1. Effect of Prognostic Guided Management of Patients With Acute Pulmonary Embolism According to the European Society of Cardiology Risk Stratification Model

Author

Jiménez, David, Rodríguez, Carmen, Pintado, Beatriz, Pérez, Andrea, Jara-Palomares, Luis, López-Reyes, Raquel, Ruiz-Artacho, Pedro, García-Ortega, Alberto, Bikdeli, Behnood, Lobo, José Luis, IPEP investigators, Instituto de Salud Carlos III, and European Commission

Subjects
Complications, pulmonary embolism, LOS, complications, Pulmonary embolism, prognosis, Mortality, Prognosis, Cardiology and Cardiovascular Medicine, mortality
Abstract

[Background] A recent trial showed that management driven by prognostic assessment was effective in reducing the length of stay (LOS) for acute stable pulmonary embolism (PE). The efficacy and safety of this strategy in each subgroup of risk stratification remains unknown., [Methods] We conducted a post-hoc analysis of the randomized IPEP study to evaluate the effect of a management strategy guided by early use of a prognostic pathway in the low- and intermediate-high risk subgroups defined by the European Society of Cardiology (ESC) model. These subgroups were retrospectively identified in the control arm. The primary outcome was LOS. The secondary outcomes were 30-day clinical outcomes., [Results] Of 249 patients assigned to the intervention group, 60 (24%) were classified as low-, and 30 (12%) as intermediate-high risk. Among 249 patients assigned to the control group, 66 (27%) were low-, and 13 (5%) intermediate-high risk. In the low-risk group, the mean LOS was 2.1 (±0.9) days in the intervention group and 5.3 (±2.9) days in the control group (P < 0.001). In this group, no significant differences were observed in 30-day readmissions (0% vs. 3.0%, respectively), all-cause (0% vs. 0%) and PE-related mortality rates (0% vs. 0%), or severe adverse events (0% vs. 1.5%). In the intermediate-high risk group, the mean LOS was 5.3 (±1.8) days in the intervention group and 6.5 (±2.5) days in the control group (P = 0.08). In this group, no significant differences were observed in 30-day readmissions (3.3% vs. 3.0%, respectively), all-cause (6.7% vs. 7.7%) and PE-related mortality rates (6.7% vs. 7.7%), or severe adverse events (16.7% vs. 15.4%)., [Conclusion] The use of a prognostic assessment and management pathway was effective in reducing the LOS for acute PE without comprising safety across subgroups of risk stratification., This work was funded by the Instituto de Salud Carlos III (PI15/00207) and cofinanced by the European Development Regional Fund “A way to achieve Europe.”

Published
2022

2. Consenso multidisciplinar para el manejo de la tromboembolia de pulmón

Author

Lobo, José Luis, Alonso, Sergio, Arenas, Juan, Domènech, Pere, Escribano, Pilar, Fernández-Capitán, Carmen, Jara-Palomares, Luis, Jiménez, Sonia, Lázaro, María, Lecumberri, Ramón, Monreal, Manuel, Ruiz-Artacho, Pedro, Jiménez, David, and en nombre del Panel Multidisciplinar para el Manejo de la TEP

Subjects
Treatment, Tromboembolia de pulmón, Diagnóstico, Diagnosis, Pulmonary embolism, Pronóstico, Tratamiento, Prognosis
Abstract

We have updated recommendations on 12 controversial topics that were published in the 2013 National Consensus on the diagnosis, risk stratification and treatment of patients with pulmonary embolism (PE). A comprehensive review of the literature was performed for each topic, and each recommendation was evaluated in two teleconferences. For diagnosis, we recommend against using the Pulmonary Embolism Rule Out Criteria (PERC) rule as the only test to rule out PE, and we recommend using a D-dimer cutoff adjusted to age to rule out PE. We suggest using computed tomography pulmonary angiogram as the imaging test of choice for the majority of patients with suspected PE. We recommend using direct oral anticoagulants (over vitamin K antagonists) for the vast majority of patients with acute PE, and we suggest using anticoagulation for patients with isolated subsegmental PE. We recommend against inserting an inferior cava filter for the majority of patients with PE, and we recommend using full-dose systemic thrombolytic therapy for PE patients requiring reperfusion. The decision to stop anticoagulants at 3 months or to treat indefinitely mainly depends on the presence (or absence) and type of risk factor for venous thromboembolism, and we recommend against thrombophilia testing to decide duration of anticoagulation. Finally, we suggest against extensive screening for occult cancer in patients with PE.

Published
2021

4. Implications of Abnormal Troponin Levels With Normal Right Ventricular Function in Normotensive Patients With Acute Pulmonary Embolism.

Author

Mirambeaux, Rosa, Le Mao, Raphael, Muriel, Alfonso, Pintado, Beatriz, Pérez, Andrea, Velasco, Diurbis, Lobo, José Luis, Barrios, Deisy, Morillo, Raquel, Bikdeli, Behnood, and Jiménez, David

Subjects
PULMONARY embolism, TROPONIN, GUIDELINES
Abstract

Among patients with pulmonary embolism (PE), various permutations of normal or abnormal cardiac troponin results and normal or abnormal echocardiographic right ventricular function are encountered in clinical practice. We aimed to explore whether there is a true gradient of risk based on troponin and echocardiographic results. This study included normotensive patients with PE from the PROgnosTic valuE of CT scan in hemodynamically stable patients with acute symptomatic pulmonary embolism (PROTECT) study. Patients were categorized as having -Troponin/-Echo, -Troponin/+Echo, +Troponin/-Echo, and +Troponin/+Echo. The primary outcome was 30-day "complicated course," including death from any cause, hemodynamic collapse, or recurrent PE. Secondary outcomes included individual adverse event rates. Of the 834 patients who had echocardiographic and troponin results, 569 patients (68%) had -Troponin/-Echo, 126 patients (15%) had -Troponin/+Echo, 74 patients (8.9%) had +Troponin/-Echo, and 65 patients (7.8%) had +Troponin/+Echo. The incidence of 30-day complicated course was 4.6% in patients with -Troponin/-Echo, 11.9% in patients with -Troponin/+Echo, 13.5% in patients with +Troponin/-Echo, and 16.9% in patients with +Troponin/+Echo (P for trend <0.001). In the subgroup of patients with a high-risk sPESI (i.e., intermediate-risk according to the ESC guidelines) (n = 527), the incidence of 30-day complicated course was 14.9% in patients with -Troponin/+Echo, 18.5% in patients with +Troponin/-Echo, and 17.5% in patients with +Troponin/+Echo (P for trend <0.01). In patiens with PE, there seems to be a risk gradient based on troponin and echocardiographic results. This study did not detect a significant risk difference in those with +Troponin/-Echo compared with -Troponin/+Echo. [ABSTRACT FROM AUTHOR]

Published
2020
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5. Interobserver reliability of echocardiography for prognostication of normotensive patients with pulmonary embolism.

Author

Kopecna, Dita, Briongos, Sem, Castillo, Hugo, Moreno, Carlos, Recio, Mónica, Navas, Paula, Lobo, José Luis, Alonso-Gomez, Angel, Obieta-Fresnedo, Izaskun, Fernández-Golfin, Covadonga, Zamorano, José Luis, and Jiménez, David

Abstract

Objectives: To evaluate the interobserver reliability of echocardiographic findings of right ventricle (RV) dysfunction for prognosticating normotensive patients with pulmonary embolism (PE). Methods: A central panel of cardiologists evaluated echocardiographic studies of 75 patients included in the PROTECT study for the following signs: RV diameter, RV/left ventricular (LV) diameter ratio, hypokinesis of the RV free wall, and tricuspid plane systolic excursion (TAPSE). Investigators used intraclass correlation to assess agreement between the measurements of the central panel and each of the local cardiologists. Investigators used the single weighted kappa statistic to test for agreement between readers of interpretation of RV enlargement and RV hypokinesis. Results: The two observers had fair agreement (к = 0.45) for RV enlargement assessed by the RV diameter, and good agreement (к = 0.65) for RV enlargement assessed by the RV/LV diameter ratio. The interobserver reliability of the assessment whether hypokinesis of the RV free wall is present was good (к = 0.70), and whether RV dysfunction (assessed by TAPSE measurement) is present was very good (к = 0.86). The intraclass correlation for the RV/LV diameter ratio was fair (0.55; 95% confidence interval [CI], 0.37-0.69), for the RV diameter was good (0.70; 95% CI, 0.56-0.80), and for the TAPSE measurement was very good (0.85; 95% CI, 0.77-0.90). On Bland-Altman analysis, the mean differences for RV diameter, RV/LV diameter ratio and TAPSE measurement were 2.33 (±5.38), 0.06 (±0.23) and 0.08 (±2.20), respectively. Conclusion: TAPSE measurement is the least user dependent and most reproducible echocardiographic finding of RV dysfunction in normotensive patients with PE. [ABSTRACT FROM AUTHOR]

Published
2014
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7. Prognostic Value of Electrocardiographic Findings in Hemodynamically Stable Patients With Acute Symptomatic Pulmonary Embolism.

Author

Escobar, Carlos, Jiménez, David, Martí, David, Lobo, José Luis, Díaz, Gema, Gallego, Paloma, Vidal, Rafael, Barrios, Vivencio, and Sueiro, Antonio

Subjects
PULMONARY embolism, PULMONARY artery diseases, ATRIAL arrhythmias, ELECTROCARDIOGRAPHY, TACHYCARDIA
Abstract

Copyright of Revista Española de Cardiología (18855857) is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Published
2008
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