Aortic intramural hematoma and pulmonary embolism are two rapidly progressive and life-threatening diseases. A 65-year-old male patient with descending aortic intramural hematoma and pulmonary embolism underwent pulmonary embolectomy and descending aortic stent-graft placement, with good postoperative results.
ObjectiveTo explore the early predictive value of Wells score and D-dimer for acute pulmonary embolism. MethodsEighty-two cases with acute pulmonary embolism comfirmed by computed tomography pulmonary angiography and (or) lung ventilation/perfusion scan were retrospectively studied from October 2013 to October 2014 in our hospital. Another 82 cases without acute pulmonary embolism in the chest pain center simultaneously were selected as control group. The data on admission were analyzed including Wells score, D-dimer, pH, PCO2, PO2, P(A-a)O2, brain natriuretic peptide, troponin I of two groups of patients. Relevant variables were selected by multivariate logistic regression analysis. The receiver operating characteristic (ROC) curve was made by sensitivity as the ordinate and 1 minus specificity as abscissa. The area under ROC curve (AUC) for relevant variables was calculated and the variable with higher AUC was selected. The best threshold, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were achieved from the ROC curves. ResultsThe multivariate logistic regression analysis showed that Wells score (OR=8.114, 95%CI 1.894-34.761, P=0.005) and D-dimer (OR=1.009, 95%CI 1.001-1.017, P=0.021) could predict APE early. The AUC, sensitivity, specificity, PPV, NPV of Wells score for the early prediction of patients with acute pulmonary embolism were 0.990, 50.0%, 100.0%, 100.0%, 66.7%, respectively. The AUC, sensitivity, specificity, PPV, NPV of D-dimer for the early prediction of patients with acute pulmonary embolism were 0.986, 95.1%, 97.6%, 97.5%, 95.2%, respectively. ConclusionWells score and D-dimer have high predictive value in patients with acute pulmonary embolism, and can be used in preliminary screening of acute pulmonary embolism in the emergency department.
Objective To compare the prognostic value of different types of simplified Pulmonary Embolism Severity Index (sPESI) in patients with acute pulmonary embolism (APE), so as to select the best scoring system for clinical application. Methods We retrospectively collected the data of consecutive patients with APE in the Fourth People’s Hospital of Zigong City from January 1st, 2014 to January 1st, 2019. The endpoint was 1-month all-cause mortality. We tried to modify sPESI by replacing arterial oxyhaemoglobin saturation with arterial partial pressure of oxygen / fraction of inspired oxygen (new scoring system named psPESI), and modify sPESI by replacing arterial oxyhaemoglobin saturation with saturation of pulse oxygen / fraction of inspired oxygen (new scoring system named ssPESI), and analyzed the area under the receiver-operating characteristic curve (AUC), net reclassification improvement (NRI), integrated discrimination improvement (IDI), calibration and decision curve. Results A total of 280 patients (109 with low-risk APE, 155 with intermediate-risk APE, and 16 with high-risk APE) were enrolled in the study. Of these patients, 165 (58.93%) were male, and the 1-month all-cause mortality rate was 10.71% (30/280). The AUCs of sPESI, psPESI and ssPESI were 0.756, 0.822 and 0.807, respectively, and the AUC of ssPESI was higher than that of sPESI (P=0.038) but not lower than that of psPESI (P=0.388). Comparing ssPESI with sPESI, the NRI was 0.928 (P<0.001) and the IDI was 0.084 (P<0.001); comparing ssPESI with psPESI, the NRI was 0.041 (P=0.227) and the IDI was –0.028 (P=0.060). The psPESI (Hosmer-Lemeshow test χ2=12.591, P=0.182) and ssPESI (Hosmer-Lemeshow test χ2=4.204, P=0.897) were well-calibrated in the internal validation cohort and obtained more net benefits within wide threshold probabilities than sPESI. Conclusion Since the saturation of pulse oxygen is non-invasive and easy to obtain, and the predictive ability of ssPESI is similar to that of psPESI, it is recommended that ssPESI be used as a new scoring system to evaluate the prognosis of APE.
ObjectiveTo evaluate the predictive value of the high-sensitivity cardiac troponin I (hs-cTnI) in patients with acute pulmonary embolism (APE). MethodsIn a retrospective cohort study,272 consecutive patients with APE were reviewed and the 30-days death and in-hospital adverse events were evaluated. The patients were classified according to hs-cTnI value into a high hs-cTnI group and a low hs-cTnI group. The simple pulmonary embolism severity index (sPESI) was used for clinical risk determination. The adverse event was defined as intravenous thrombolytic therapy,noninvasive ventilator support to maintain oxygen saturation >90% and suffered with severe complications. The correlations of hs-cTnI with sPESI score,30-days adverse events and mortality were analyzed. The Kaplan-Meier curves and the log-rank test were used to compare time-to-event survival. Stepwise multivariate logistic regression analysis models were used to determine the incremental prognostic value of sPESI score and hs-cTnI. ResultsThe incidence of 30-day death (6.1%),renal failure (14.6%),bleeding (13.4%) and thrombolytic therapy (7.9%) were higher in the high hs-cTnI group than those in the low hs-cTnI group (P values were 0.009,<0.001,0.018 and 0.003,respectively). The patients with sPESI ≥1 and low hs-cTnI had greater free adverse events survival (P=0.005). hs-cTnI provided incremental predictive value for in-hospital adverse events,beyond the sPESI score (P<0.001). Conclusionhs-cTnI has excellent negative predictive value of APE prognosis,especially when used combined with sPESI score.
Venous thromboembolism (VTE), comprising both deep vein thrombosis and pulmonary embolism, is a chronic illness that contributes significantly to the global burden of disease. The American College of Chest Physicians (ACCP) published the 9th edition of antithrombotic treatment guidelines for VTE (AT9) in 2012, which was first updated in 2016. In October 2021, ACCP published the 2nd update to AT9, which addressed 17 clinical questions related to VTE and presented 29 guidance statements in total. In this paper we interpreted the recommendations proposed in this update of the guidelines.
ObjectiveTo explore the diagnostic value of the bedside echocardiogram for different risk stratification of patients with suspected pulmonary embolism. MethodsPatients with suspected pulmonary embolism in the emergency department of the Second Afflicted Hospital Xi'an Jiaotong University between July 2013 to December 2015 were included. According the Wells scores, they were divided into a low risk group (0-2 points), a intermediate risk group (3-6 points) and a high risk group (>6 points). All patients were underwent the bedside echocardiogram diagnosis, and the diagnostic value of the echocardiography for pulmonary embolism, the characteristics of different risk stratification of patients were analyzed by SPSS 18.0 software. Results115 patients with suspected pulmonary embolism were included, of which 20 were in the low risk group, 73 were in the medium risk group, and 22 were in the high risk group. The incidence of pulmonary embolism among the three groups was significantly different (high-risk vs. medium risk vs. low-risk: 90.9% vs. 76.7% vs. 15.0%, P<0.05), and the higher Wells scores gets, the greater possibility of having the pulmonary embolism. For the intermediate-risk group, the incidence of pulmonary embolism was significantly higher in patients with positive ultrasonic results than those with the negative ultrasonic results (87.3% vs. 44.4%, P<0.05). The predication of the ultrasonic positive and the negative in the low and high risk groups had no statistical differences (P>0.05). The result of echocardiogram showed that the right ventricular end-diastolic diameter, right ventricular end-diastolic transverse diameter, right atrial end-diastolic transverse diameter, RV/LV, RA/LA in the high risk group and the intermediate risk group were significantly higher than those in the low risk group (all P values <0.05). The right ventricular anterior wall activity in the low risk group was higher than that in the high risk group (P<0.05), but this difference was not found between the high risk group and the intermediate risk group. ConclusionBedside echocardiogram can be used as the diagnosis and differential diagnosis methods of suspected pulmonary embolism, and it has relatively higher diagnostic value for intermediate to high risk patients predicted by the Wells scores than low risk ones.
Objective To analyze the clinical features of rickettsial infection complicated with pulmonary embolism and to improve clinicians’ knowledge of rickettsial infection complicated by thromboembolism events. Methods We retrospectively analyzed the clinical data of a patient with pulmonary thromboembolism complicated by Rickettsial felis infection and conducted a review of the relevant literature. The search terms "Rickettsia/Scrub typhus, thrombosis" or "Rickettsia/ Scrub typhus, embolism" were used to search the Wanfang ,VIP ,Chinese National Knowledge Infrastructure and PubMed databases from January 1985 to May 2023, respectively. Results The 81-year-old male patient was admitted to the hospital on June 1, 2021 due to "dizziness, sore throat for 11 days, fever for 7 days, and shortness of breath for 3 days". Physical examination revealed a eschar-like rash behind the left ear, venous thrombosis in both lower limbs was detected by color ultrasound, computed tomographic pulmonary angiography indicated multiple pulmonary embolism in both lungs, and positive rickettsiae on peripheral blood next-generation sequencing, confirming the diagnosis of Rickettsial felis infection complicated by venous thromboembolism (VTE) in both lower limbs and pulmonary embolism. Twenty manuscripts, including 20 cases, were retrieved from databases. Among them, Rickettsial felis infection combined with thromboembolism event was not found. With the addition of our case, a total of 21 cases were analyzed in detail. Six of the 21 cases were complicated with VTE, 10 with pulmonary embolism, 5 with intracranial venous thrombosis, 6 with thrombosis at other sites (jugular venous thrombosis, mesenteric thrombosis, aortic thrombosis, etc), and 8 of which had concurrently involved systemic thrombosis. Of the 4 deaths, 2 cases had mesenteric embolism, 1 case had cerebral infarction, and 1 case had systemic multiple thrombus. Conclusions Rickettsial infection symptoms and signs are often atypical, can be complicated with lower limb VTE or pulmonary embolism. Early identification, diagnosis and treatment are very important, especially for patients with dyspnea, chest pain and other related symptoms.
Objective To explore the causal association between obstructive sleep apnea (OSA) and venous thromboembolism (VTE). Methods Using the summary statistical data from the FinnGen biological sample library and IEU OpenGWAS database, the relationship between OSA and VTE, including deep vein thrombosis (DVT) and pulmonary embolism, was explored through Mendelian randomization (MR) method, with inverse variance weighted (IVW) as the main analysis method. Results The results of univariate MR analysis using IVW method showed that OSA was associated with VTE and pulmonary embolism (P<0.05), with odds ratios and 95% confidence intervals of 1.204 (1.067, 1.351) and 1.352 (1.179, 1.544), respectively. There was no correlation with DVT (P>0.05). Multivariate MR analysis showed that after adjustment for confounding factors (smoking, diabetes, obesity and cancer), OSA was associated with VTE, DVT and pulmonary embolism (P<0.05), with odds ratios and 95% confidence intervals of 1.168 (1.053, 1.322), 1.247 (1.064, 1.491) and 1.158 (1.021, 1.326), respectively. Conclusion OSA increases the risk of VTE, DVT, and pulmonary embolism.
Objective To investigate the prognostic value of troponin I ( cTNI) , brain natriuretic peptide ( BNP) and D-dimer in acute pulmonary embolism ( APE) .Methods The plasma levels of cTNI, BNP, and D-dimer were measured in 98 consecutive patients with APE at the time of admission. The relationship between these parameters and mortality were evaluated. Results APE was diagnosed in 98 consecutive patients during January 2009 to December 2010, in which 49 were males and 49 were females. 14 ( 14. 3% ) patients died at the end of follow-up. The patients with positive cTNI tests had more rapid heart rates, higher rate of syncope, cardiogenic shock and mortality than the patients with normal serumcTNI. However the age and blood pressure were lower in the patients with abnormal serum cTNI ( P lt; 0. 05) . A receiver-operating characteristic curve analysis identified BNP≥226. 5 ng/L was the best cut-off value ( AUC 0. 829, 95% CI 0. 715-0. 942) with the negative predictive value of 97. 1% for death. The mortality of the patients whose serum D-dimer level ranging from 500 to 2499 ng/mL, 2500 to 4999 ng/mL, and ≥5000 ng/mL was 7. 8% , 12% , and 41. 2% , respectively ( P = 0. 009) . Upon multivariate analysis, cardiogenic shock ( OR=2. 931, 95% CI 0. 828-12. 521, P =0.000) , cTNI≥0. 3 ng/mL ( OR=1. 441, 95% CI 0. 712-4. 098, P = 0. 0043) , BNP gt; 226. 5 ng/L ( OR = 1. 750, 95% CI 0. 690-6. 452, P = 0. 011) and D-dimer≥5000 ng/mL( OR = 1. 275, 95% CI 0. 762-2. 801, P = 0. 034) were independent predictors of death. Conclusions Combined monitoring of cTNI, BNP or D-dimer levels is helpful for prognosis prediction and treatment decision for APE patients.
ObjectiveTo investigate the difference in fibrinogen and D-dimer (D-D) level among pulmonary embolism patients with different risk stratification. MethodsSixty pulmonary embolism patients admitted during January 2013 and January 2014 in our hospital were retrospectively analyzed.The general clinical data were gathered, and the patients were divided into a high-risk group (n=19), a moderate-risk group (n=21), and a low-risk group (n=20) according to the 2008 ESC Guidelines on the diagnosis and management of acute pulmonary embolism.Fourteen patients admitted simultaneously with dyspnea and chest pain without pulmonary embolism were randomly recruited as a control group.The plasma levels of fibrinogen and D-D were detected and compared between these groups. ResultsIn the pulmonary embolism patients, there were no significant statistical differences in general data between the patients with different risk degree.With the risk degree increased, the level of fibrinogen decreased and the level of D-D increased (P < 0.05).Compared with the pulmonary embolism patients, the level of fibrinogen was higher and the level of D-D was lower in the control group(P < 0.05).The level of fibrinogen was negatively correlated with the level of D-D with a correlation coefficient of-0.805. ConclusionsElevated fibrinogen is one of high risk factors of the pulmonary embolism. With the occurrence of pulmonary embolism, the level of fibrinogen becomes lower, suggesting the potential of fibrinogen as a indicator for pulmonary embolism diagnosis and risk stratification.