Diagnosis and prognosis of acute pulmonary embolism: focus on serum troponins

Pulmonary embolism is a common disease associated with high mortality. Death due to pulmonary embolism occurs mainly before hospital admission or in the first hours of the hospital stay. Prompt diagnosis and prognostic stratification and more intensive treatment in patients with estimated high risk for adverse outcomes have the potential to reduce mortality due to pulmonary embolism. Significant advances have recently been made in the risk stratification for adverse outcomes in patients with pulmonary embolism and normal blood pressure. In these patients, right ventricle overload assessed by echocardiography and probably by helical computerized tomography is a predictor of in-hospital mortality. Serum troponin is rapidly available in the emergency room, and has a critical role in the management of patients with acute coronary syndromes. The role of serum troponin in patients with pulmonary embolism has been explored recently: it seems to be marginal in diagnosis while it can significantly contribute to prognostic stratification. Elevated serum levels of troponins are associated with right ventricular overload and adverse in-hospital outcomes in patients with pulmonary embolism and normal blood pressure.     

Comparison of troponin I and N-terminal-pro B-type natriuretic peptide for risk stratification in patients with pulmonary embolism.

OBJECTIVE: We compared the usefulness of plasma N-terminal-pro B-type natriuretic peptide and troponin I levels for risk stratification of patients with pulmonary embolism. METHODS: This was a prospective study performed in an emergency department. N-terminal-B-type natriuretic peptide assay and troponin I were performed blindly at admission in patients with pulmonary embolism confirmed by imaging tests. A complicated pulmonary embolism was defined as any of the following: death, cardiopulmonary resuscitation, requirement for mechanical ventilation, use of pressors, thrombolysis, surgical embolectomy or admission in an intensive care unit. RESULTS: Sixty patients (mean age+/-standard deviation of 72+/-15 years) were included. Seventeen (28%) patients had adverse events: all were admitted in intensive care unit, one was treated with surgical embolectomy and one with thrombolysis, and three died. The median N-terminal-pro B-type natriuretic peptide level (95% confidence interval) was higher in the group of patients with complicated pulmonary embolism, 4086 pg/ml (505-8998) versus 352 pg/ml (179-662), respectively (P<0.05). The mean value of troponin I was similar in the complicated pulmonary embolism group, 0.09+/-0.17 microg/l versus 0.08+/-0.41 microg/l, respectively (P=0.93). The best threshold value of N-terminal-pro B-type natriuretic peptide was 1000 pg/ml, and the receiver operating characteristic curve demonstrated that N-terminal-pro B-type natriuretic peptide significantly predicted the complicated pulmonary embolism with an area under the receiver operative curve of 0.72 (0.58-0.83) (P<0.05), whereas troponin I did not [area under the receiver operative curve of 0.58 (0.42-0.71)]. CONCLUSION: Unlike troponin I, N-terminal-pro B-type natriuretic peptide may be an accurate marker of in-hospital complication after pulmonary embolism.     

Which type of observation for patients with high-risk mild head injury and negative computed tomography?

OBJECTIVE: Current guidelines suggest hospital admission followed by home monitoring for high-risk patients with mild head injury and negative computed tomography scan. We tested early home monitoring under the care of a competent observer. METHODS: A total of 1480 patients with mild head injury and negative computed tomography scan were prospectively studied. Based on clinical status and available home caretakers, patients were managed by in-hospital observation (n = 646) or early home monitoring (n = 834). Outcome measures were: (1) the detection of previously undiagnosed post-traumatic intracranial injury; (2) neurosurgical intervention; and (3) unfavourable outcome (death, permanent vegetative state or severe disability). RESULTS: In the in-hospital arm, nine cases (1.4%) developed intracranial injuries (in three after discharge). In the early home-monitoring arm, six patients (0.7%) had a previously undiagnosed lesion after re-admission (P = 0.773 versus in-hospital arm). No patients with previously undiagnosed intracranial injuries had a neurosurgical intervention. After 6 months, five patients had died in the home monitoring arm (0.8%) versus eight (1.0%) in the in-hospital arm (P=0.785). No permanent disability or vegetative state was observed. CONCLUSION: Early home monitoring may be safely proposed to selected "high-risk" patients, with an early negative computed tomography scan, normal clinical examination and feasible home monitoring.     

探寻肺栓塞脉搏血氧饱和度的目标区间

目的 探讨肺栓塞患者氧疗期间脉搏血氧饱和度(pulse oxygen saturation,SpO2)与院内全因死亡风险的关系.方法 检索2014—2015年eICU数据库中美国多家医院以肺栓塞为主要诊断的病历资料.以院内全因死亡为因变量,氧疗期间中位SpO2为自变量构建广义相加模型(generalized addit...     

Detection of central pulmonary artery thromboemboli by transesophageal echocardiography in patients with severe pulmonary embolism.

Transthoracic echocardiography generally provides only indirect signs of pulmonary embolism. In contrast, with transesophageal echocardiography the thromboembolus itself can be visualized in the central parts of the pulmonary artery. The aims of our study were to evaluate, first, the incidence of central pulmonary artery thromboemboli in patients with severe pulmonary embolism, and second, the accuracy of the echocardiographic diagnosis. Our study group comprised 60 patients with proved severe pulmonary embolism. All patients were examined by transthoracic and transesophageal echocardiography. The echocardiographic findings concerning the absence or presence of central pulmonary artery thromboemboli were compared with the results of different reference methods. Central pulmonary thromboemboli were found in 35 patients (58.3%) by echocardiography. Two types of thrombus were differentiated. Type A is a long, highly mobile thrombus, and type B is an immobile wall-adherent thrombus. In comparison with the reference methods, we determined a sensitivity of 96.7% and a specificity of 88% for the echocardiographic detection of central pulmonary artery thromboemboli in patients with severe pulmonary embolism. Transesophageal echocardiography seems to be a useful method for the diagnosis of severe pulmonary embolism. In our series, central pulmonary artery thromboemboli were present in more than half of the patients. In these cases, transesophageal echocardiography can clarify the diagnosis within a few minutes without further invasive diagnostic procedures.     

Wheezing in patients with acute pulmonary embolism with and without previous cardiopulmonary disease.

BACKGROUND: Wheezing is a little known but possible presentation feature of acute pulmonary embolism. PATIENTS AND METHODS: A retrospective review of the records of 154 consecutive patients with acute pulmonary embolism, who survived long enough for diagnostic evaluation. RESULTS: Fourteen patients with acute pulmonary embolism (9.1%) had wheezing at presentation. Wheezing was more frequent in patients with previous cardiopulmonary disease than in those without previous cardiopulmonary disease, although this did not reach statistical significance (13.5 versus 6.9%; P=0.17). Dyspnoea, cough and respiratory failure were more frequent with statistical significance in our patients with wheezing than in those without wheezing. The hospital mortality rate was similar in both groups. CONCLUSION: Wheezing in acute pulmonary embolism may be more frequent in patients with previous cardiopulmonary disease. However, wheezing also occurs in patients with acute pulmonary embolism without previous cardiopulmonary disease. Wheezing may be a sign of severity in acute pulmonary embolism.     

A More Aggressive Approach to Emergency Embolectomy for Acute Pulmonary Embolism

OBJECTIVE: To examine operative outcomes after acute pulmonary embolectomy (APE), a recently adopted, more aggressive surgical approach.PATIENTS AND METHODS: We retrospectively identified patients who underwent surgical APE from April 1, 2001, through March 31, 2009, and reviewed their clinical records for perioperative outcome. Operations were performed with normothermic cardiopulmonary bypass and a beating heart, absent a patent foramen ovale. For completeness, embolectomy was performed via separate incisions in the left and right pulmonary arteries (PAs) in 15 patients.RESULTS: Of the 18 patients identified, the mean age was 60 years, and 13 patients (72%) were men. Thirteen patients (72%) had been hospitalized recently or had systemic disease. The preoperative diagnosis was established by echocardiography or computed tomography (or both). The median (range) follow-up time for all surviving patients was 16 months (2-74 months). Indications for APE included cardiogenic shock (n=12; 67%) and severe right ventricular dysfunction as shown by echocardiography (n=5; 28%). Seven patients (39%) had an embolus in transit. Seven patients (39%) experienced cardiopulmonary arrest before APE. Four early deaths (22%) occurred; all 4 of these patients had preoperative cardiopulmonary arrest, and 2 had APE via the main PA only, without branch PA incisions. Two late deaths (11%) occurred. Right ventricular function improved in all survivors.CONCLUSION: The results of emergent APE are encouraging, particularly among patients without cardiopulmonary arrest. It should not be reserved for patients in extremis; rather, it should be considered for patients with right ventricular dysfunction that is an early sign of impending hemodynamic collapse.ACCP = American College of Chest Physicians; APE = acute pulmonary embolectomy; CPR = cardiopulmonary resuscitation; ECMO = extracorporeal membrane oxygenation; IVC = inferior vena cava; PE = pulmonary embolism; PEA = pulseless electrical activity; PFO = patent foramen ovale; PTE = pulmonary thromboendarterectomy; RV = right ventricularAcute massive pulmonary embolism (PE) is associated with considerable mortality and morbidity, despite advances in diagnosis and therapy.¹ Aggressive anticoagulation is the mainstay of therapy. However, in the presence of hemodynamic compromise, pharmacologic lytic therapy² or catheter-based rheolytic therapy³ may be considered. Surgical embolectomy became the treatment of last resort at most institutions after early reports showed poor outcomes.^4,5 However, in many reported cases, surgery was considered only after hemodynamic collapse, and a high percentage of deaths occurred among patients with preoperative cardiopulmonary arrest. More recent reports suggest satisfactory outcomes when echocardiographic evidence of right ventricular (RV) dysfunction prompts surgical intervention before hemodynamic collapse occurs.^6,7 On the basis of these reports, we have recently adopted a more aggressive approach to acute pulmonary embolectomy (APE) at our institution. Accordingly, we examine our current operative results of APE.     

Crossing atrial thrombus in a patient with recurrent pulmonary embolism

OBJECTIVES: To report the detection of a thrombus entrapped in a patent foramen ovale by echocardiography in a patient with recurrent pulmonary embolism. DESIGN: Case report. SETTING: Intensive care unit of a university hospital. PATIENT: A 62-yr-old man with initial deep venous thrombosis and recurrent minor pulmonary embolism followed by a severe embolic event with transitory hemiparesis 10 days after prostatectomy. INTERVENTION: Systemic anticoagulation, surgical removal of a crossing atrial thrombus, closure of a patent foramen ovale, and venous thrombectomy. MEASUREMENTS AND MAIN RESULTS: Transesophageal echocardiography revealed a large thrombus entrapped in a patent foramen ovale with portions in all four heart chambers. Intraoperatively, a 19-cm-long thrombus, shaped like the pelvic veins, was found. The patient was successfully weaned from cardiopulmonary bypass, requiring temporary positive inotropic support because of right ventricular dysfunction. Within 24 hrs of the operation, the patient was discharged to the intermediate care unit. CONCLUSIONS: Recurrent pulmonary embolism can potentially result in paradoxic embolism in patients with a patent foramen ovale. In such patients, it may be crucial to monitor right ventricular function and exclude right-to-left shunts by transesophageal echocardiography, regardless of clinical symptoms. The patent foramen ovale should be closed. This case emphasizes an important indication for transesophageal echocardiography in critically ill patients.     

Prospective Study of the Clinical Features and Outcomes of Emergency Department Patients with Delayed Diagnosis of Pulmonary Embolism

Objectives: The authors hypothesized that emergency department (ED) patients with a delayed diagnosis of pulmonary embolism (PE) will have a higher frequency of altered mental status, older age, comorbidity, and worsened outcomes compared with patients who have PE diagnosed by tests ordered in the ED.
Methods: For 144 weeks, all patients with PE diagnosed by computed tomographic angiography were prospectively screened to identify ED diagnosis (testing ordered from the ED) versus delayed diagnosis (less than 48 hours postadmission). Serum troponin I level, right ventricular hypokinesis on echocardiography, and percentage pulmonary vascular occlusion were measured at diagnosis; patients were prospectively followed up for adverse events (death, intubation, or circulatory shock).
Results: Among 161 patients with PE, 141 (88%) were ED diagnosed and 20 (12%) had a delayed diagnosis. Patients with a delayed diagnosis were older than ED-diagnosed patients (61 [±15] vs. 51 [±17] years; p < 0.001), had a longer median time to heparin administration (33 vs. 8 hours; p < 0.001), and had a higher frequency of altered mental status (30% vs. 8%; p = 0.01) but did not have a higher frequency of prior cardiopulmonary disease (25% vs. 23%). Patients with a delayed diagnosis had equal or worse measures of PE severity (right ventricular hypokinesis on echocardiography, 60% vs. 58%; abnormal troponin I level, 55% vs. 24%); on computed tomographic angiography, ten of 20 patients with a delayed diagnosis had PE in lobar or larger arteries and >50% vascular obstruction. Patients with a delayed diagnosis had a higher rate of in-hospital adverse events (9% vs. 30%; p = 0.01).
Conclusions: In this single-center study, the diagnosis of PE was frequently delayed and outcomes of patients with delayed diagnosis were worse than those of patients with PE diagnosed in the ED.     

D-dimer levels correlate with mortality in patients with acute pulmonary embolism: Findings from the RIETE registry

OBJECT: Few studies have addressed the prognostic implications of D-dimer in patients with pulmonary embolism. The aim of this study was to investigate the correlation between D-dimer levels and mortality in patients with pulmonary embolism. DESIGN: Observational study. SETTING: Hospitals participating in the Registro Informatizado de la Enfermedad Tromboembólica (RIETE). PATIENTS: A total of 588 consecutive patients with symptomatic pulmonary embolism who were included in the RIETE between March 2001 and December 2004. INTERVENTIONS: Quantitative D-dimer measurement was performed on admission using an automated latex agglutination test (IL Test D-dimer). All patients underwent clinical follow-up for 3 months. MEASUREMENTS AND MAIN RESULTS: Overall mortality rate was 10.5%. The cause of death was pulmonary embolism in 18 patients (3.0%), fatal bleeding in one patient (0.2%), and other causes in 43 patients (7.3%). There were 28 (4.8%) nonfatal venous thromboembolism recurrences and 35 (6.0%) nonfatal bleeding episodes. The incidence of D-dimer 500-2499 ng/mL, D-dimer 2500-4999 ng/mL, and D-dimer >or=5000 ng/mL was 47.8%, 26.0%, and 20.4%, respectively. Compared with patients with D-dimer 500-2499 ng/mL, the relative risk (odds ratio) of overall mortality was 1.91 (95% confidence interval 0.91-4.09) and 2.94 (95% confidence interval 1.42-6.25) in patients with D-dimer 2500-4999 ng/mL and D-dimer >or= 5000 ng/mL, respectively (p = .032). Patients with D-dimer >or=5000 ng/mL showed higher risk of death from fatal pulmonary embolism (odds ratio 4.4, 95% confidence interval 0.5-33.0) than death from other causes (odds ratio 2.1, 95% confidence interval 0.7-6.0). Elevated D-dimer levels were associated with more severe disease, as assessed by clinical features. CONCLUSIONS: In patients who present with pulmonary embolism, D-dimer concentration is an independent predictive factor associated with all-cause and pulmonary embolism-related death. D-dimer >or=5000 ng/mL occurs in about one in five patients and is associated with a 2.9-fold increased risk of overall mortality. These results suggest that D-dimer quantification could be a useful biomarker and help determine initial therapies.     

Pacemaker endocarditis: clinical features and management of 60 consecutive cases

BACKGROUND: The incidence of endocarditis related to pacemakers is increasing, while the diagnosis and management remain difficult. The objective of this study was to evaluate the clinical features and management of endocarditis after implantation of pacemakers (PM) or cardioverter defibrillators (ICD). METHODS: We analyzed the hospital course of 60 consecutive patients (48 men, mean age 68 +/- 12 years) admitted to our center for PM (n = 59) or ICD (n = 1) endocarditis between 1998 and 2004. RESULTS: Fever (78%), asthenia (65%), and local symptoms (35%) were common. Positive cultures were obtained in 53 cases (Staphylococcus 89%). Sixteen patients (27%) had pulmonary embolism. Vegetations (mean size 15.2 +/- 8 mm, range 5 to 35 mm) were found in 54 cases (90%), with transthoracic echocardiography in 26 cases (43%), and transesophageal echocardiography (TEE) in 50 cases (89% of the 56 patients who had TEE). Devices were removed surgically (n = 20) or percutaneously (n = 37). In the surgical group, vegetations were larger (17.9 +/- 7 mm vs 13.2 +/- 7 mm, P = 0.01). After removal, 42 patients (70%) had a new PM. Mortality factors (6 deaths - follow up 3.4 +/- 2 years) were the number of vegetations and absence of extraction of the device (P < 0.02). Clinical features and management of the 37 patients with early onset endocarditis (within 1 year after implantation) did not differ from those with late onset. CONCLUSIONS: PM endocarditis was essentially staphylococcal. TEE was required for the diagnosis of vegetations. Complete removal of the device is required and associated with a favorable outcome.     

急性肺栓塞溶栓治疗的短期预后影响因素:病例对照研究

  目的  探究急性肺栓塞溶栓治疗患者的短期预后相关因素。  方法  回顾性收集2014年1月至2017年11月北京协和医院经计算机断层扫描肺血管造影或超声心动图确诊并接受重组组织型纤溶酶原激活剂溶栓治疗的急性肺栓塞患者的临床资料, 包括基础疾病、病程、临床特征、实验室检查、影像学表现、治疗及转归等, 结合简化版肺栓塞严重指数, 分析患者溶栓后7、14、30 d预后相关危险因素。  结果  共23例符合纳入和排除标准的患者入选本研究, 其中男性5例, 女性18例, 平均年龄(57.3±14.0)岁。16例患者存活(69.6%, 16/23), 7例死亡(30.4%, 7/23), 7 d病死率为26.1%(6/23), 14 d及30 d病死率均为30.4%(7/23)。与存活组相比, 死亡组患者sPESI更高[3(2, 3)比2(1, 2), P=0.008], 收缩压[(79.3±25.4)mm Hg比(108.7±18.1) mm Hg, P=0.005]、血小板计数[(135.1±58.3)×10⁹/L比(223.2±89.4)×10⁹/L, P=0.012]、血钙浓度[(1.9±0.2)mmol/L比(2.1±0.2)mmol/L, P=0.030]均更低, N端脑钠肽前体水平更高[6372(1637, 17 228)pg/ml比1166(343, 1821)pg/ml, P=0.035], 心肺复苏更常见(100%比12.5%, P=0.000)。单因素生存分析显示, 心率>110次/min(P=0.012)、收缩压 < 90 mm Hg(P=0.000)、进行心肺复苏(P=0.000)或N端脑钠钛前体水平>6000 pg/ml(P=0.001)的患者14 d生存率更低, 而无恶性肿瘤、无慢性心肺疾病、动脉血氧饱和度≥ 90%、血小板≥ 200×10⁹/L或血钙≥ 2.00 mmol/L并不能显著改善14 d存活情况。  结论  在急性肺栓塞溶栓患者中, 低血压、心肺复苏、较高心率及N端脑钠肽前体水平可能预示着更高的短期死亡风险, 低血钙、低血小板能否作为短期死亡预测因子仍需进一步研究论证。     

Neurologic manifestations of cerebral air embolism as a complication of central venous catheterization

OBJECTIVE, PATIENTS, AND METHODS: A severe case of cerebral air embolism after unintentional central venous catheter disconnection was the impetus for a systematic literature review (1975-1998) of the clinical features of 26 patients (including our patient) with cerebral air embolism resulting from central venous catheter complications. RESULTS: The jugular vein had been punctured in eight patients and the subclavian vein, in 12 patients. Embolism occurred in four patients during insertion, in 14 patients during unintentional disconnection, and in eight patients after removal and other procedures. The total mortality rate was 23%. Two types of neurologic manifestations may be distinguished: group A (n = 14) presented with encephalopathic features leading to a high mortality rate (36%); and group B (n = 12) presented with focal cerebral lesions resulting in hemiparesis or hemianopia affecting mostly the right hemisphere, with a mortality rate as high as 8%. In 75% of patients, an early computed tomography indicated air bubbles, proving cerebral air embolism. Hyperbaric oxygen therapy was performed in only three patients (12%). A cardiac defect, such as a patent foramen ovale was considered the route of right to left shunting in 6 of 15 patients (40%). More often, a pulmonary shunt was assumed (9 of 15 patients; 60%). For the remainder, data were not available. CONCLUSION: When caring for critically ill patients needing central venous catheterization, nursing staff and physicians should be aware of this potentially lethal complication.     

Diagnostic value of gas exchange tests in patients with clinical suspicion of pulmonary embolism

OBJECTIVE: To assess the value of parameters derived from arterial blood gas tests in the diagnosis of pulmonary embolism. METHOD: We measured alveolar-arterial partial pressure of oxygen [P(A-a)O2] gradient, PaO2 and arterial partial pressure of carbon diaxide (PaCO2) in 773 consecutive patients with suspected pulmonary embolism who were enrolled in the Prospective Investigative Study of Acute Pulmonary Embolism. DIAGNOSIS: The study design required pulmonary angiography in all patients with abnormal perfusion scans. RESULTS: Of 773 scans, 270 were classified as normal/near-normal and 503 as abnormal. Pulmonary embolism was diagnosed by pulmonary angiography in 312 of 503 patients with abnormal scans. Of 312 patients with pulmonary embolism, 12, 14 and 35% had normal P(A-a)O2, PaO2 and PaCO2, respectively. Of 191 patients with abnormal scans and negative angiograms, 11, 13 and 55% had normal P(A-a)O2, PaO2 and PaCO2, respectively. The proportions of patients with normal/near-normal scans who had normal P(A-a)O2, PaO2 and PaCO2 were 20, 25 and 37%, respectively. No differences were observed in the mean values of arterial blood gas data between patients with pulmonary embolism and those who had abnormal scans and negative angiograms. Among the 773 patients with suspected pulmonary embolism, 364 (47%) had prior cardiopulmonary disease. Pulmonary embolism was diagnosed in 151 (41%) of 364 patients with prior cardiopulmonary disease, and in 161 (39%) of 409 patients without prior cardiopulmonary disease. Among patients with pulmonary embolism, there was no difference in arterial blood gas data between patients with and those without prior CPD. CONCLUSION: These data indicate that arterial blood gas tests are of limited value in the diagnostic work-up of pulmonary embolism if they are not interpreted in conjunction with clinical and other laboratory tests.     

Carotid sonography and transesophageal echocardiography in patients with ischemic stroke or transient ischemic attack in the territory of the carotid artery

PURPOSE: To assess the benefit of combining carotid sonography and transesophageal echocardiography (TEE) for the evaluation of patients with stroke or transient ischemic attack (TIA) in the territory of the carotid artery. METHODS: During a 2-year period in Turku University Hospital, consecutive in patients with stroke or TIA who were candidates for carotid endarterectomy and for oral anticoagulation were evaluated with carotid sonography for symptomatic moderate (50-69%) or severe (>or=70%) internal carotid artery (ICA) stenosis, and with TEE for potential cardiac sources of embolism. RESULTS: In 20% (40/197) of patients, a severe symptomatic ICA stenosis and/or a major risk factor for a cardiac source of embolism were found. In 56% (110/197) of patients, a moderate or severe symptomatic ICA stenosis and/or a potential cardiac source of embolism were found, whereas 11% (21/197) of patients had both a moderate or severe symptomatic ICA stenosis and a potential cardiac source of embolism. CONCLUSIONS: This study suggests that the presence of a moderate or severe symptomatic ICA stenosis does not exclude the presence of a potential cardiac source of embolism and vice versa. Carotid sonography and TEE complement each other and are valuable diagnostic tools that should be recommended in patients with ischemic stroke or TIA in the territory of the carotid artery when they are candidates for carotid endarterectomy and for oral anticoagulation.     

Plasma concentrations of von Willebrand factor and intracellular adhesion molecule-1 for prediction of outcome after successful cardiopulmonary resuscitation

OBJECTIVE: Ischemia/reoxygenation following cardiopulmonary resuscitation might cause endothelial injury/activation that could contribute to an adverse outcome after cardiopulmonary resuscitation. We studied plasma concentrations of von Willebrand factor (vWF) antigen and soluble intracellular adhesion molecule (sICAM)-1 as markers of a generalized endothelial injury/activation in relation to outcome after cardiopulmonary resuscitation. DESIGN: Retrospective study on stored plasma samples. SETTING: Intensive care unit at a university hospital. PATIENTS: Thirty-five patients who survived >24 hrs after in- or out-of-hospital cardiopulmonary resuscitation and 15 noncritically ill control patients.I NTERVENTIONS: Blood sampling. MEASUREMENTS AND MAIN RESULTS: Plasma concentrations of vWF antigen and sICAM-1 on day 2 after cardiopulmonary resuscitation were higher in patients than in controls (p < .001 and p = .001, respectively). In-hospital cardiopulmonary resuscitation, cardiopulmonary resuscitation duration > or = 15 mins, severe cardiovascular failure, and renal dysfunction/failure at the time of blood sampling were associated with significant elevations in vWF antigen and sICAM-1 concentrations. Patients with an unfavorable outcome after cardiopulmonary resuscitation (cerebral performance category > or = 3) exhibited higher vWF antigen and sICAM-1 concentrations than patients with good outcome (cerebral performance category 1-2; p < .001 and p = .097, respectively). Renal dysfunction/failure, severe cardiovascular failure, systemic inflammatory response syndrome, and cardiopulmonary resuscitation duration > or = 15 mins were also associated with higher adverse outcome rates. Combination of these four variables into a cardiac arrest risk score (levels 0-4) showed adverse outcome rates of 100, 56, and 0% in patients with arrest scores of 4, 2-3, and 0-1, respectively. A vWF antigen concentration >166% was an independent predictor of outcome after cardiopulmonary resuscitation (p = .002) and was associated with increased adverse outcome rates in patients with cardiac arrest risk scores of 2-3. Furthermore, both vWF antigen concentrations >166% and sICAM-1 concentrations >500 ng/mL had 100% specificity for an adverse outcome in patients after out-of-hospital cardiopulmonary resuscitation but were less predictive in patients after in-hospital cardiopulmonary resuscitation. CONCLUSIONS: vWF antigen and sICAM-1 might be useful adjunctive variables for early determination of outcome in patients after successful out-of-hospital cardiopulmonary resuscitation.     

Initial symptoms in pulmonary embolism differ from those in pneumonia: a retrospective study during seven years.

OBJECTIVE: To compare initial symptoms in pulmonary embolism with community-acquired pneumonia and relate to C-reactive protein and pulmonary infiltrates in order to improve the clinical assessment at the emergency department. METHODS: A retrospective review of patients with pulmonary embolism diagnosed in the clinic for infectious diseases (CID), (n=25), and a randomized sample of patients with pulmonary embolism diagnosed in the department of medicine (n=64), and a randomized sample of patients with community-acquired pneumonia (n=54) diagnosed in the clinic for infectious diseases. RESULTS: Initial symptoms in pulmonary embolism, dominated by dyspnoea and/or pleuritic chest pain were significantly different from those in community-acquired pneumonia, dominated by fever, chills and/or cough (P<0.001). On admission, C-reactive protein and body temperature were significantly higher and pulmonary infiltrates were more common in pneumonia compared with randomized pulmonary embolism patients. Twenty-five patients with a final diagnosis of pulmonary embolism were erroneously suspected of having lung infection, owing to increased C-reactive protein, presence of pulmonary infiltrates and/or high fever. However, they had classical symptoms of pulmonary embolism. CONCLUSIONS: Pulmonary infiltrates, high fever and a high level of C-reactive protein can deceive the physician to suspect pneumonia instead of pulmonary embolism. Classical initial symptoms ought to direct the physician in diagnosing pulmonary embolism. We emphasize a detailed patient history of initial symptoms.     

Genetic variations observed in arterial and venous thromboembolism--relevance for therapy, risk prevention and prognosis.

We undertook genetic and biochemical assays in patients with arterial (n = 146) and venous (n = 199) thromboembolism and survivors of pulmonary embolism (n = 58) to study causation and gene-life style interactions. In the clinical material from North Western Russia, factor V Leiden was found to be a risk factor in venous thrombosis (OR = 3.6), while the methylenetetrahydrofolate reductase (MTHFR) C677T mutation was a significant variable in both venous (p = 0.03) and arterial thrombosis (p = 0.004). Homocysteine levels were determined (n = 84) and hyperhomocysteinemia correlated with the T allele of the MTHFR gene, and with smoking and coffee consumption. Vitamin supplementation reduced homocysteine levels dependent on MTHFR genotype (36% TT, 25% CT, 22% CC). In pulmonary embolism patients, frequency of the -455G/A beta-fibrinogen dimorphism was studied. Carriers of this allele were significantly underrepresented (p < 0.02) among pulmonary embolism survivors (34.5%) compared to controls (56.7%). Additionally, -455AA homozygotes were found in 11.7% controls but only 1.7% of pulmonary embolism patients (p = 0.006). In venous and arterial thrombosis cases, MTHFR and homocysteine data led to effective dietary supplementation with a reduced risk of disease progression. Results from the pulmonary embolism study may indicate that screening tests for the -455G/A beta-fibrinogen genetic variation could be of prognostic value, and may point the way for novel anticoagulation strategies.     

Transesophageal echocardiography for the diagnosis of pulmonary embolism with acute cor pulmonale: a comparison with radiological procedures

Objective: The goal of the study was to assess prospectively the value of transesophageal echocardiography (TEE) for the diagnosis of massive pulmonary embolism complicated by acute cor pulmonale. Design: A prospective study conducted on 44 consecutive patients. Setting: A general intensive care unit (ICU) of a university hospital. Patients and methods: Between May 95 and October 96, 44 consecutive patients with clinically suspected acute pulmonary embolism underwent transthoracic echocardiography (TTE), completed by TEE when acute cor pulmonale was present (30 patients). The results of the echocardiographic studies were compared with radiological investigations by helical CT or contrast angiography. Results: The high sensitivity and specificity of the presence of acute cor pulmonale on TTE for the diagnosis of pulmonary embolism was confirmed. Nineteen patients only underwent TEE. The sensitivity and the specificity of TEE in detecting a proximal pulmonary embolism were 84 % and 84 %, respectively. Its main limitation concerned the left pulmonary artery, in which only one thrombus was visualized by TEE whereas six were present on helical CT, and lobar pulmonary arteries which could not be visualized with TEE. Thus, the overall sensitivity of TEE for the detection of pulmonary embolism with acute cor pulmonale was only 58 %. Conclusion: In comparison with radiological procedures, TEE had limited accuracy for detecting pulmonary embolism with acute cor pulmonale. When the pulmonary embolism was located in the main or right pulmonary artery, TEE could clarify the diagnosis within a few minutes without further invasive diagnostic procedures. However, a negative TEE did not exclude left proximal or lobar pulmonary embolism. Received: 28 April 1997 Accepted: 28 November 1997     

Characteristics and outcomes of cancer patients requiring mechanical ventilatory support for >24 hrs

OBJECTIVES: To describe the characteristics of a large cohort of cancer patients receiving mechanical ventilation for >24 hrs and to identify clinical features predictive of in-hospital death. DESIGN: Prospective cohort study. SETTING: Ten-bed oncologic medical-surgical intensive care unit. PATIENTS: A total of 463 consecutive patients were included over a 45-month period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Data were collected on the day of admission to the intensive care unit. The intensive care unit and hospital mortality rates were 50% and 64%, respectively. There were 359 (78%) patients with solid tumors and 104 (22%) with hematologic malignancies; 35 (8%) patients had leukopenia. Sepsis (63%), coma (15%), invasion or compression by tumor (11%), pulmonary embolism (7%), and cardiopulmonary arrest (6%) were the main reasons for mechanical ventilation. The independent unfavorable risk factors for mortality were older age (odds ratio, 3.09; 95% confidence interval, 1.61-5.93, for patients 40-70 yrs old, and odds ratio, 9.26; 95% confidence interval, 4.16-20.58, for patients >70 yrs old); performance status 3-4 (odds ratio, 2.51; 95% confidence interval, 1.40-4.51); cancer recurrence/progression (odds ratio, 3.43; 95% confidence interval, 1.81-6.53); Pao2/Fio2 ratio <150 (odds ratio, 2.64; 95% confidence interval, 1.40-4.99); Sequential Organ Failure Assessment score (excluding respiratory domain, each 4 points; odds ratio, 2.34; 95% confidence interval, 1.70-3.24); and airway/pulmonary invasion or compression by tumor as a reason for mechanical ventilation (odds ratio, 5.73; 95% confidence interval, 1.92-17.08). CONCLUSIONS: Severity of acute organ failures, poor performance status, cancer status, and older age were the main determinants of mortality. The appropriate use of such easily available clinical characteristics may avoid forgoing intensive care for patients with a chance of survival.