Funding Acknowledgements Type of funding sources: None. Background During the COVID-19 pandemic many countries have imposed lockdown restrictions to movement. Since the 18th of March in Portugal, thousands of people have been confined to their homes. While hospital admissions for COVID-19 patients increased exponentially, admissions for non-COVID-19 patients decreased dramatically. However, it remains unclear whether lockdown-related immobility can contribute to the increased incidence of pulmonary embolism. Purpose To compare the incidence of pulmonary embolism (PE) during the lockdown period (Abril 1 to May 31, 2020) compared to the reference period in 2019. Methods Retrospective study of consecutive outpatients who presented to the emergency department and underwent computed tomography pulmonary angiography (CTPA) due to suspicion of PE. Results Compared to the same period of 2019, the lockdown period was associated with a significant increase in PE diagnosis (29 versus 18 patients). PE patients during lockdown were older (median age 71 years; interquartile range [IQR][60-85] versus 59 years [44-76]; p = 0.046) and have lower prevalence of active cancer (14% versus 33% in the reference period). Women represent 55% (n = 16) of patients in lockdown group (versus 50% in 2019 group). Clinical probability (GENEVA score) was similar in both groups (median score 2.72 in lockdown group and 2.50 in reference group, p = 0.452). None of the patients with PE was diagnosed with COVID-19. Conclusion We have observed a marked increase (62%) in PE diagnosis during lockdown period compared to the reference period, which can be explained by the reduction in physical activity due to teleworking and closure of gyms and sports activities. These data reinforce the importance of promoting physical activity programs at home. The role of pharmacological or mechanical thromboprophylaxis in this scenario remains unclear.
Funding Acknowledgements Type of funding sources: None. Background Ruling out pulmonary embolism (PE) through a combination of clinical assessment and Ddimer is crucial to avoid excessive computed tomography pulmonary angiography (CTPA), and different algorithms should be considered as an alternative to the fixed cutoff to achieve that goal. Purpose To compare sensitivity, specificity, and reduction in CTPA requests of 4 algorithms to rule out PE: fixed Ddimer cutoff, age-adjusted, YEARS and PEGeD. Methods Retrospective study of consecutive outpatients who presented to the emergency department and underwent CTPA for PE suspicion from April 2019 to February 2020. The clinical-decision algorithms were retrospectively applied. In fixed and age-adjusted cutoffs, high probability patients are directly selected for CTPA and the others perform CTPA if Ddimer ≥500µg/L or age x10 µg/L within patients over 50 years, respectively. YEARS includes 3 items (signs of deep vein thrombosis, haemoptysis and whether PE is the most likely diagnosis): patients without any YEARS items and Ddimer ≥1000ng/mL or with ≥1 items and Ddimer 500ng/mL perform CTPA. In the PEGeD, patients with high clinical probability or with intermediate and Ddimers >500µg/L or low probability and Ddimer >1000 µg/L are selected for CTPA. Results We enrolled 409 patients and PE was confirmed by CTPA in 125 patients. Compared with a fixed Ddimer cutoff, age-adjusted was associated with a significant increased of specificity (p < 0.001), correctly avoiding 29 CTPAs, without losing sensitivity. YEARS resulted in a marked increase in specificity, compared to the fixed cutoff, but with an impairment of sensitivity(p = 0.002). PEGeD had the worst sensitivity, associated with 11 more false negatives (FN) than the fixed cutoff. Despite the lack of difference between PEGed and YEARS strategies regarding sensitivity, YEARS had a significantly higher specificity (p < 0.001) and allowed to correctly avoid a higher number of CTPA(55 vs 63), compared to the fixed cutoff. Results are summarized in table 1. Conclusion Compared to fixed d-dimer cutoff, all algorithms were associated with an increased specificity. Age-adjusted cutoff was the only that is not associated with a significant decrease in sensitivity when compared to fixed cutoff, allowing to safely reduce the need to perform CTPA. Sens(%) Spec(%) Correctly avoid CTPAs(n) FN(n) Fixed cutoff 95 29 85 6 Age-adjusted 93 40 114 9 YEARS 87 52 148 16 PEGeD 86 49 140 17
Funding Acknowledgements Type of funding sources: None. Introduction Adverse hemodynamic effects of right ventricular pacing are known, and the optimal right ventricular lead position is still being a matter of debate. According to the guidelines, upgrade to cardiac resynchronization therapy (CRT) is recommended in patients with indication for pacemaker and left ventricular ejection fraction less than 50% or who need more than 40% of ventricular pacing. Purpose To compare clinical outcomes and ejection fraction in patients with previous pacemaker (apical versus septal right ventricular pacing) who are upgrated to CRT. Methods Single-center retrospective study of 94 consecutive patients who had previous pacemaker and upgraded to CRT over a 4-year period. Of these patients, 64 had previous apical lead pacemaker and 30 had previous septal lead pacemaker. Data on comorbidities, New York Heart Association (NYHA), left ventricular ejection fraction and hospitalizations due to heart failure were collected. The results were obtained using Chi-square, Mann-Whitney and t-test. Results Patients with septal pacemaker had significantly more diabetes (p = 0.04) and chronic obstructive pulmonary disease (p = 0.01), tended to be more symptomatic (p = 0.198) and had more days of hospitalization before and after pacemaker implantation (12 ± 3 versus 7 ± 2 days and 8 ± 4 versus 3 ± 1 days, respectively), mostly due heart failure decompensation. Although there were no significant differences in the initial ejection fraction in patients with apical or septal pacemaker implantation (31.2 ± 1.2% and 29.1 ± 1.5%, respectively, p = 0.323), the time to upgrade to CRT was significantly shorter in patients with septal pacemaker implantation (1999 ± 227 days versus 3005 ± 279 days, p = 0.005). After upgrading to CRT, patients with apical lead had a significant increase in ejection fraction (8.2%, p = 0.011), while patients with septal lead had a non-significant improvement of ejection fraction (4.5%, p = 0.448). In both, apical and septal lead patients, there was a significant improvement in NYHA class after upgrade to CRT (p = 0.03 and p = 0.02, respectively). Conclusion Although patients with septal lead had more comorbidities and hospitalizations due to heart failure, they do not benefit from the upgrade to CRT, unlike what happens in patients with apical lead. These findings can be explained by the fact that the septal lead minimizes ventricular desynchrony induced by right ventricular pacing.
Funding Acknowledgements Type of funding sources: None. Introduction Age affects the performance of the diagnostic tests to rule out pulmonary embolism (PE), particularly with a decrease in specificity, leading to an overuse of computed tomography pulmonary angiography (CTPA). Current guidelines advice to consider using the age-adjusted cut-off in patients older than 50 years, but no specific recommendation is provided for very old patients. We aimed to compare the age-dependency of the diagnostic accuracy of the standard approach (based on Wells and Geneva scores combined with a D-dimer cut-off of 500 ng/mL), with three alternative strategies (age-adjusted, YEARS and PEGeD algorithms) in patients admitted to the Emergency Department (ED) due to PE suspicion. Methods Consecutive outpatients admitted to the ED who underwent CTPA due to PE suspicion were retrospectively evaluated. The diagnostic accuracy was calculated and compared among the different diagnostic prediction rules and stratified by age. Results We included 1402 patients (mean age 69 years, 54% female). PE was confirmed in 25% (n=353), 86% occurred in patients over 50 years. Table 1 and 2 represents the sensitivity and specificity of diagnostic prediction rules stratified by age. For all diagnostic strategies, specificity decreases with age. In patients over 80 years, the standard approach’s specificity could be as low as 8%. Compared to the standard approach, the age-adjusted strategy was associated with higher specificity over 50 years (p=0.008 for patients aged 51-60 years; p<0.001 for patients over 60 years), with similar sensitivities for patients under 70 years and a non-statistically significant decrease in sensitivity in patients over 70 years (p=0.03). YEARS and PEGeD algorithms had the highest specificities for all ages (p£0.001). Regarding sensitivity, except for patients aged between 61 and 70 years, YEARS and PEGeD showed lower sensitivity than the standard and age-adjusted approaches for all ages (p<0.001), particularly in patients under 60 years (sensitivity of 81% in patients aged between 51-60 years). Conclusion Compared to the standard approach, an age-adjusted strategy increased specificity with a non-significant decrease in sensitivity only in patients older than 70. YEARS and PEGeD algorithms had the highest specificity across all ages yet were associated with a significant decrease in sensitivity.
Funding Acknowledgements Type of funding sources: None. Background Pulmonary embolism (PE) is more prevalent in patients with cancer. D-dimers are a less useful test in such patients due to less specificity. Several algorithms have been developed as an alternative to the fixed d-dimer cutoff, aiming to avoid the excessive use of computed tomography pulmonary angiography (CTPA), but it is not clear which is the most accurate algorithm in PE patients with cancer. Objective To compare the efficacy of 4 algorithms to rule out pulmonary embolism (fixed Ddimer cutoff, age-adjusted, YEARS and PEGed) in patients with active cancer. Methods Retrospective study of consecutive outpatients who presented to the emergency department and underwent CTPA for PE suspicion from April 2019 to February 2020. The clinical-decision algorithms were retrospectively applied. In fixed and age-adjusted cutoffs, high probability patients are directly selected for CTPA and the others perform CTPA if DDimer ≥500µg/L or age x10 µg/L within patients over 50 years, respectively. YEARS includes 3 items (signs of deep vein thrombosis, haemoptysis and whether PE is the most likely diagnosis): patients without any YEARS items and Ddimer ≥1000ng/mL or with ≥1 items and Ddimer 500ng/mL perform CTPA. In the PEGeD, patients with high clinical probability or with intermediate and Ddimer >500µg/L or low probability and Ddimer >1000 µg/L are selected for CTPA. Results Of 409 patients with suspected PE, 87 patients (21,3%) had cancer. The prevalence of PE was 38% in cancer patients and 35% in patients without cancer (p > 0.05). Age-adjusted cut-off, compared to the conventional cutoff, had an AUC significantly higher (0.68 vs 0.61, p = 0.005). Despite both having 100% sensitivity, age-adjusted cutoff had a significant higher specificity compared to conventional cut-off (44% vs 35%, p < 0.05). Both YEARS and PEGED algorithms had significantly lower sensitivity (p = 0.003 and p = 0.002, respectively) and higher specificity (p < 0.001, for both) compared to conventional cutoff in patients with active cancer. The AUC of these two algorithms was not significantly different compared to conventional cutoff (p = 0.08 and p = 0.78, respectively). Conclusion Considering our results, age-adjusted cut-off seems to be the most accurate algorithm to rule out pulmonary embolism in active cancer patients. Sen(%)Spec(%)Conventional10022Age-adjusted10035YEARS9144PEGED9130Abstract Figure. AUC of four algorithms
Funding Acknowledgements Type of funding sources: None. Background Ruling out pulmonary embolism (PE) through a combination of clinical assessment and Ddimer is crucial to avoid excessive computed tomography pulmonary angiography (CTPA), and different algorithms should be considered as an alternative to the fixed cutoff to achieve that goal. Purpose To compare diagnostic performance of 4 algorithms to rule out PE: fixed Ddimer cutoff, age-adjusted, YEARS and PEGeD. Methods Retrospective study of consecutive outpatients who presented to the emergency department and underwent CTPA for PE suspicion from April 2019 to May 2020. In fixed and age-adjusted cut-off, high probability patients are directly selected for CTPA. Low to moderate probability patients perform CTPA if Ddimer ≥500µg/L in fixed cutoff, and in age-adjusted cutoff if Ddimer ≥500µg/L in patients who are ≤ 50 years of age, and if Ddimer level was more than 10 times the patient’s age in patients older than 50 years. YEARS includes 3 items (signs of deep vein thrombosis, haemoptysis and whether PE is the most likely diagnosis): patients without any YEARS items and Ddimer ≥1000ng/mL or with ≥1 items and Ddimer 500ng/mL perform CTPA. In the PEGeD, patients with high clinical probability or with intermediate and Ddimers >500µg/L or low probability and Ddimer >1000 µg/L are selected for CTPA. Results We enrolled 571 patients and PE was confirmed by CTPA in 172. Compared with a fixed Ddimer cutoff, age-adjusted was associated with a significant increase of specificity (p < 0.001), correctly avoiding 38 CTPAs, without losing sensitivity. YEARS and PEGED resulted in a increase in specificity, compared to the fixed cutoff, but with an impairment of sensitivity (p < 0.001). PEGeD had the worst sensitivity (13 more false negatives (FN) than the fixed cutoff). Despite the lack of difference between PEGed and YEARS strategies regarding sensitivity, PEGED had a significantly higher specificity (p < 0.001) and allowed to correctly avoid a higher number of CTPA (95 vs 85), compared to the fixed cutoff. Conclusion Compared to fixed d-dimer cutoff, all algorithms were associated with an increased specificity. Age-adjusted cutoff was the only that is not associated with a significant decrease in sensitivity when compared to fixed cutoff, allowing to safely reduce the need to perform CTPA. Sen(%)Spec(%)Correctly avoid CTPAs(n)FN(n)Fixed cutoff251017Age-adjusted933513912YEARS894718619PEGED884919620
Funding Acknowledgements Type of funding sources: None. Introduction Patient education is considered a core component of cardiac rehabilitation (CR) and nowadays, particularly during the COVID-19 pandemic, online education programs are critical. However, the best strategy for implementing these digital programs to increase patients’ adherence and learning is not fully established. Purpose To assess the uptake and effectiveness of an educational intervention transmitted through video sessions integrated into a home-based CR program (CR-HB). Methods Prospective cohort study including patients (pts) who were participating in a centre-based CR program and accepted to participate in a CR-HB program during COVID-19 pandemic. The CR-HB program consisted of a multidisciplinary online program with educational videos for pts and family members / caregivers, that aimed to educate on necessary behavioural and lifestyle changes. Weekly, a 15-minute video was uploaded and lectured by the correspondent health professional from the CR team. The educational sessions covered the following topics: COVID-19 and cardiovascular (CV) disease, coronary artery disease, hypertension, dyslipidemia, smoking cessation, diabetes, medical therapy and adherence, healthy diet, exercise and physical activity, sedentary behaviour and sexual dysfunction and CV disease. At the end of the program we applied a 10 questions questionnaire to evaluate the knowledge of pts about the topics of educational sessions. All the pts answered the questionnaire and results were compared between the pts who attended the educational sessions and the ones who didn’t. Results 116 pts with CV disease were included in the CR-HB program (62.6 ± 8.9 years, 95 males). Almost 90% (n = 103) of the participants had coronary artery disease and the mean LVEF was 52 ± 11%. Obesity was the most common risk factor (75%) followed by hypertension (60%), family history of CV disease (42%), dyslipidemia (38%), diabetes (18%), and smoking (13%). The pts participated, on average, in 1.45 ± 2.6 education sessions (rate participation of 13.2%). About half of the pts (49%) attended, at least, one session and these pts attended, on average, 3 sessions (2.96 ± 3.0). The questionnaire results were better in pts who attended at least 1 educational session than in those who did not attend any (7.4 ± 1.9 vs 7,1 ± 1.7), however this difference was not statistically significant. Regarding education status, 33 pts (45.2%) had a bachelor degree and this group of pts had a significant higher result in questionnaire (7.8 ± 1.9 vs 6.7 ± 1.8; p = 0.015) and tended to participate more often in education sessions (2.13 vs 1.6, p = 0.06). Conclusions Our study showed a low rate of participation in sessions, highlighting the importance of developing strategies to increase motivation and adherence to online educational programs. Also, more literate patients had significantly greater health knowledge and adherence to educational sessions, suggesting that this population could benefit more from this type of programs.
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