Association Between Right Ventricular Function and Perfusion Abnormalities in Hemodynamically Stable Patients With Acute Pulmonary Embolism

Miller, Rachel L.; Das, Sam; Anandarangam, Thiruvengadam; Leibowitz, David; Alderson, Philip O.; Thomashow, Byron; Homma, Shunichi

doi:10.1378/chest.113.3.665

Cited by 73 publications

(37 citation statements)

References 28 publications

(7 reference statements)

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“…In previous studies based on angiography or scintigraphy results (35)(36)(37)(38), researchers found that RV failure resulting from both arterial obstruction and underlying cardiopulmonary conditions is a better determinant of mortality than PA clot load alone. In acute PE with severe arterial pulmonary hypertension, RV dilation results in an increased RV/LV ratio.…”

Section: Discussionmentioning

confidence: 99%

Severe Pulmonary Embolism:Pulmonary Artery Clot Load Scores and Cardiovascular Parameters as Predictors of Mortality

Ghaye¹,

Ghuysen²,

Willems³

et al. 2006

Radiology

229

141

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Purpose:To retrospectively evaluate pulmonary artery (PA) clot load scores and computed tomographic (CT) cardiovascular parameters as predictors of mortality in patients with severe pulmonary embolism (PE). Materials and Methods:Institutional review board approval was obtained with waiver of informed consent. A total of 82 consecutive patients (42 women, 40 men; mean age Ϯ standard deviation, 61 years Ϯ 15) were admitted to the intensive care unit for PE-related conditions and were evaluated by using CT pulmonary angiography. Two independent readers who were blinded to clinical outcome quantified PA clot load by using four scoring systems. Cardiovascular measurements included right ventricular (RV) and left ventricular (LV) short-axis measurements; RV short axis to LV short axis (RV/LV) ratios; main PA, ascending aorta, azygos vein, and superior vena cava diameters; and main PA diameter to aorta diameter ratios. Reflux of contrast medium into the inferior vena cava, leftward bowing of the interventricular septum, pleural or pericardial effusion, pulmonary consolidation, infarct, platelike atelectasis, and mosaic ground-glass opacity were also recorded. Results were correlated with patient outcome during hospital stay by using the Wilcoxon rank sum and 2 tests. Results:Twelve patients died within 1-14 days. RV and LV short axis; RV/LV ratio; azygos vein, superior vena cava, and aorta diameters; and contrast medium reflux into the inferior vena cava were significantly different between survivors and nonsurvivors (P Ͻ .05). No significant relationship was found between PA clot load and mortality rate. RV/LV ratio and azygos vein diameter allowed correct prediction of survival in 89% of patients (P Ͻ .001). Conclusion:RV/LV ratio and azygos vein diameter are predictors of mortality in patients with severe PE.

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Section: Discussionmentioning

confidence: 99%

Severe Pulmonary Embolism:Pulmonary Artery Clot Load Scores and Cardiovascular Parameters as Predictors of Mortality

Ghaye¹,

Ghuysen²,

Willems³

et al. 2006

Radiology

229

141

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“…83 The etiology of right ventricular dysfunction in patients with acute PE is multifactorial, as there is a limited correlation between this finding and the extent of perfusion defects, even in patients without prior cardiopulmonary disease. 90 …”

Section: Right Ventricular Dysfunction Without Shockmentioning

confidence: 99%

Natural History of Venous Thromboembolism

2003

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Abstract-Most deep vein thromboses (DVTs) start in the calf, and most probably resolve spontaneously. Thrombi that remain confined to the calf rarely cause leg symptoms or symptomatic pulmonary embolism (PE). The probability that calf DVT will extend to involve the proximal veins and subsequently cause PE increases with the severity of the initiating prothrombotic stimulus. Although acute venous thromboembolism (VTE) usually presents with either leg or pulmonary symptoms, most patients have thrombosis at both sites at the time of diagnosis. Proximal DVTs resolve slowly during treatment with anticoagulants, and thrombi remain detectable in half of the patients after a year. Resolution of DVT is less likely in patients with a large initial thrombus or cancer. About 10% of patients with symptomatic DVTs develop severe post-thrombotic syndrome within 5 years, and recurrent ipsilateral DVT increases this risk. About 10% of PEs are rapidly fatal, and an additional 5% cause death later, despite diagnosis and treatment. About 50% of diagnosed PEs are associated with right ventricular dysfunction, which is associated with a Ϸ5-fold greater in-hospital mortality. There is Ϸ50% resolution of PE after 1 month of treatment, and perfusion eventually returns to normal in two thirds of patients. About 5% of treated patients with PE develop pulmonary hypertension as a result of poor resolution. After a course of treatment, the risk of recurrent thrombosis is higher (ie, Ϸ10% per patient-year) in patients without reversible risk factors, in those with cancer, and in those with prothrombotic biochemical abnormalities such as antiphospholipid antibodies and homozygous factor V Leiden.

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“…Landmark angiographic studies showed that pulmonary artery pressure increases when thromboemboli occlude more than 30-50% of the total cross-sectional area of the pulmonary arterial bed [9]. Several studies have suggested that the correlation between the extent of mechanical embolic obstruction and the degree of pulmonary hypertension is relatively modest [10]. Indeed, pulmonary embolism with obstruction of only 25% of the pulmonary vascular tree can cause marked pulmonary hypertension, while wider obstructions can cause only slight increases in pulmonary arterial pressure [11].…”

Section: Pathophysiology Of Acute Pulmonary Embolismmentioning

confidence: 99%

Anticoagulant treatment for acute pulmonary embolism: a pathophysiology-based clinical approach

Agnelli

Becattini

2015

Eur Respir J

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The management of patients with acute pulmonary embolism is made challenging by its wide spectrum of clinical presentation and outcome, which is mainly related to patient haemodynamic status and right ventricular overload. Mechanical embolic obstruction and neurohumorally mediated pulmonary vasoconstriction are responsible for right ventricular overload. The pathophysiology of acute pulmonary embolism is the basis for risk stratification of patients as being at high, intermediate and low risk of adverse outcomes. This risk stratification has been advocated to tailor clinical management according to the severity of pulmonary embolism.Anticoagulation is the mainstay of the treatment of acute pulmonary embolism. New direct oral anticoagulants, which are easier to use than conventional anticoagulants, have been compared with conventional anticoagulation in five randomised clinical trials including >11 000 patients with pulmonary embolism. Patients at high risk of pulmonary embolism (those with haemodynamic compromise) were excluded from these studies. Direct oral anticoagulants have been shown to be as effective and at least as safe as conventional anticoagulation in patients with pulmonary embolism without haemodynamic compromise, who are the majority of patients with this disease. Whether these agents are appropriate for the acute-phase treatment of patients at intermediate-high risk pulmonary embolism (those with both right ventricle dysfunction and injury) regardless of any risk stratification remains undefined. @ERSpublications New oral anticoagulants are efficacious and safe in haemodynamically stable patients with acute pulmonary embolism http://ow.ly/I2iP5

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Association Between Right Ventricular Function and Perfusion Abnormalities in Hemodynamically Stable Patients With Acute Pulmonary Embolism

Cited by 73 publications

References 28 publications

Severe Pulmonary Embolism:Pulmonary Artery Clot Load Scores and Cardiovascular Parameters as Predictors of Mortality

Severe Pulmonary Embolism:Pulmonary Artery Clot Load Scores and Cardiovascular Parameters as Predictors of Mortality

Natural History of Venous Thromboembolism

Anticoagulant treatment for acute pulmonary embolism: a pathophysiology-based clinical approach

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