Role of echocardiography and cardiac biomarkers in prediction of in-hospital mortality and long-term risk of brain infarction in pulmonary embolism patients

IntroductionThe aim of prospective study was to evaluate the ability of echocardiography and cardiac biomarkers to predict in-hospital mortality and the risk of brain infarction during a 12-month follow-up period (FUP) with anticoagulation in pulmonary embolism (PE) patients.MethodsEighty-eight consecutive acute PE patients (39 men, mean age 63 years) were enrolled; 78 underwent baseline echocardiography and brain magnetic resonance imaging (MRI). After a 12-month FUP, 58 underwent brain MRI. In-hospital mortality and the rates of new ischemic brain lesions (IBL) on MRI with clinical ischemic stroke (IS) events were predicted based on echocardiography (patent foramen ovale presence with right-to-left shunt – PFO/RLS; right/left ventricle diameter ratio – RV/LD; tricuspid annulus plane systolic excursion – TAPSE; tricuspid annulus systolic velocity – S_T; pulmonary artery systolic pressure – PASP) and biomarkers results (amino-terminal fragment of brain natriuretic peptide – NT-proBNP and cardiac troponin T – cTnT).ResultsOur series involved 88 patients, of whom 11 (12.5%) presented high-risk PE, 24 (27.3%) intermediate-high risk PE, 19 (21.6%) intermediate-low risk PE and 34 (38.6%) patients had low risk PE.Nine patients (10.2%) died during hospitalization including high-risk PE [6/9 (66.6%)] and intermediate-high-risk PE [3/24 (12.5%)]. cTnT [odds ratio (OR) 4.3; 95% confidence interval 0.59–31.3, P = 0.014], NT-proBNP (OR 14.2 [1.5–133.4], P = 0.02), RV/LD ≥0.79 (OR 36.6 [4.2–316.4], P = 0.001), TAPSE (OR 0.55 [0.34–0.92, P = 0.022) and PASP ≥51.5 mmHg (OR 33.3 [3.8–292.6], P = 0.022) were predictors of in-hospital mortality.Seventeen patients (19.3%) experienced IS (n = 8) or new IBL (n = 9). On multivariate analysis, PFO/RLS (OR 27.1 [3.0–245.3], P = 0.003) and S_T ≤14.5 cm/s (OR 34.1 [CI 3.4–344.0], P = 0.003) were independent predictors of IS and IBL risk.ConclusionsHigh blood troponin T, NT-proBNP, RV dilatation/systolic dysfunction and pulmonary hypertension predicted in-hospital mortality. PFO/RLS presence and S_T were predictors of clinically apparent/silent brain infarction.     

Mansoor's Self-Report Tool for Cardiovascular Risk Assessment predicts adverse in-hospital events in patients with pulmonary embolism

Background

Pulmonary embolism (PE) is a life-threatening acute disease accompanied by high morbidity and mortality. Regarding hospitalizations of patients with PE, risk stratification of these patients is crucial. Thus, risk stratification tools like risk scores are of key interest.

Methods

The nationwide German inpatient sample of the years 2005–2018 was used for this present analysis. Hospitalized PE patients were stratified according to Mansoor's Self-Report Tool for Cardiovascular Risk Assessment class, and the performance of this score was evaluated to predict adverse in-hospital events.

Results

Overall, 1 174 196 hospitalizations of PE patients (53.5% females; 56.4% ≥70 years) were registered in Germany between 2005 and 2018. According to the Mansoor's self-report tool for cardiovascular risk assessment, 346 126 (29.5%) PE patients were classified as high risk. Higher Mansoor's Self-Report Tool for Cardiovascular Risk Assessment class was predictive for in-hospital death (OR 1.129 [95%CI 1.117–1.141], P < 0.001), shock (OR 1.117 [95%CI 1.095–1.140], P < 0.001), cardiopulmonary resuscitation (OR 1.109 [95%CI 1.092–1.126], P < 0.001), right ventricular dysfunction (OR 1.039 [95%CI 1.030–1.048], P < 0.001), intracerebral bleeding (OR 1.316 [95%CI 1.275–1.358], P < 0.001), and gastro-intestinal bleeding (OR 1.316 [95%CI 1.275–1.358], P < 0.001). Systemic thrombolysis was not associated with lower in-hospital mortality in high-risk class (OR 5.139 [95%CI 4.961–5.323], P < 0.001).

Conclusions

Prognostic performance of the Mansoor's Self-Report Tool for Cardiovascular Risk Assessment for risk stratification of PE patients was poor and not able to identify those PE patients, who might benefit from systemic thrombolysis. However, the Mansoor's Self-Report Tool for Cardiovascular Risk Assessment was moderately helpful to identify PE patients at higher risk for bleeding events.     

Incidence and clinical predictors of pulmonary embolism in severe heart failure patients admitted to a coronary care unit

OBJECTIVES: To determine the incidence of clinical pulmonary embolism (PE) in a population with severe congestive heart failure (CHF) admitted to a coronary care unit (CCU), and to identify clinical predictors of PE in this population. DESIGN AND SETTING: Prospective, observational study performed in a CCU of a tertiary care hospital between July 2001 and March 2003. PATIENTS: One hundred ninety-eight patients with severe decompensated CHF. MEASUREMENTS AND RESULTS: Of 198 patients recruited, 18 patients (9.1%) received a diagnosis of PE during their hospitalization. Deep vein thrombosis was demonstrated in 8 of 18 patients (44.4%) with PE. Thromboprophylaxis was used by 12 of 18 patients (66.7%) with PE and 126 of 180 patients (70%) without PE (p = 0.77). Both groups were similar with respect to mean age (68.2 +/- 14.1 years vs 69.6 +/- 13.4 years [+/- SD]), proportion of male patients (61.1% vs 55.1%), markers of CHF severity (New York Heart Association functional class > II, ejection fraction < 30%, Na < 136 mEq/L, ischemic etiology), and comorbid conditions (diabetes mellitus, atrial fibrillation, chronic renal failure, hypertension) [p = not significant]. The presence of PE was significantly associated with cancer (relative risk [RR], 8.4; 95% confidence interval [CI], 3.9 to 18.1), immobilization (RR, 5.4; 95% CI, 2.0 to 14.4), previous venous thromboembolism (VTE) [RR, 4.4; 95% CI, 1.7 to 11.3], COPD (RR, 3.1; 95% CI, 1.03 to 9.2), and right ventricle (RV) abnormality (RR, 3.3; 95% CI, 1.3 to 8.0). In a multiple logistic regression analysis, only cancer (odds ratio [OR], 26.9; 95% CI, 4.9 to 146.8), RV abnormality (OR, 9.7; 95% CI, 2.2 to 42.6), and previous VTE (OR, 9.1; 95% CI, 1.28 to 64.7) remained independently associated with PE. CONCLUSIONS: In patients with severe decompensated CHF admitted to a CCU, the incidence of clinical PE is very high despite adequate prophylaxis. Traditional risk factors seemed to play an important role in determining the risk of PE in this population.     

The role of echocardiography in suspected and established PE

Acute obstruction of more than 30% of the pulmonary arterial bed often results in abnormal right ventricular (RV) transthoracic Doppler echocardiography (TTE), usually defined as RV dysfunction, dilatation, or hypokinesis. The presence of such changes strongly increases the clinical probability of pulmonary embolism (PE) (specificity, 81 to 94%; PPV, 71 to 86%) and indicates a worse prognosis, especially if a patent foramen ovale is found at contrast TTE. Normal RV echocardiography indicates a good prognosis. Integrating TTE with venous ultrasound and transesophageal imaging increases the possibility of immediate definitive justification for specific therapy. This strategy permits direct visualization of thrombi either in proximal veins, pulmonary arteries, or right heart chambers. Mobile thrombi require immediate thrombolysis or urgent embolectomy. Whether any echo-based criteria might identify normotensive patients with PE who should receive thrombolytic therapy remains a subject for an overdue large prospective trial.     

Massive pulmonary embolism: what level of aggression?

Massive pulmonary embolism (PE) with hemodynamic instability (e.g., hypotension and cardiac shock) is associated with a poor prognosis and high mortality rates (> 50%). Accordingly patients with massive PE should be treated aggressively with thrombolytic agents (or surgical or interventional procedures). Streptokinase, urokinase, and recombinant tissue plasminogen activator (rtPA) have been used, with generally similar results. Among patients with submassive PE [i.e., subclinical right ventricular (RV) dysfunction and normal blood pressure], the role of thrombolytic therapy is controversial. Thrombolytic therapy is generally NOT indicated in normotensive patients without RV dysfunction. In this context, some experts recommend prompt administration of thrombolytic agents to prevent cardiogenic shock but data affirming benefit over heparin alone are lacking. Thrombolytic therapy is generally NOT indicated in normotensive patients without RV dysfunction. The role of echocardiography, computed tomographic (CT) scans, and cardiac biomarkers (e.g., troponins, brain natriuretic peptide, etc.) to identify patients who might benefit from aggressive thrombolytic therapy remains controversial. This article reviews indications for thrombolysis in massive PE, with an emphasis on recent data derived from normotensive patients. Further, we propose a diagnostic and therapeutic algorithm for treating acute PE. Additional studies are required to determine the benefit and safety of thrombolytic therapy for PE.     

Hypomethylation of the miRNA-34a gene promoter is associated with Severe Preeclampsia

Purpose: PE is a pregnancy-specific complication, which genetic and epigenetic factors play key roles in its pathogenesis. DNA methylation is a main epigenetic alteration with important roles in gene regulation. Micro RNAs (miRNAs) as another member of epigenetic machinery regulate the gene expression and involve in different biological pathways including apoptosis and placental development. Therefore, the present study performed to assess the association between miRNA-34a promoter methylation and PE susceptibility. Methods: The placenta of 104 PE pregnant women and 119 normotensive pregnant women were collected after delivery. The methylation status of the miRNA-34a promoter was assessed using Methylation Specific PCR (MSP). Results: The frequency of the hemi-methylated (MU) miR-34a promoter was significantly lower in PE women compared to the controls (17.3 vs. 29.4%) (OR, 0.45 [95% CI, 0.2–0.9], P = 0.016). The overall methylation rate was 23.1% in PE women and 41.2% in the control group and was significantly lower in PE women (OR, 0.4 [95% CI, 0.2–0.8], P = 0.004). The frequency of hemi-methylated (MU) and overall methylated (MU+MM) promoter of miR-34a gene was significantly lower in severe PE but not in mild PE women compared to the controls [(OR, 0.3 [95% CI, 0.1–0.8], P = 0.02) and (OR, 0.3 [95% CI, 0.1–0.7], P = 0.009), respectively]. There was an association between hemi-methylated (MU) and overall methylated (MU+MM) promoter and late onset PE [(OR, 0.4 [95% CI, 0.2–0.9], P = 0.03) and (OR, 0.4 [95% CI, 0.2–0.8], P = 0.01), respectively]. Conclusions: An association was found between hypo-methylation of the miR-34a promoter and PE and PE severity.     

Outcomes in patients with rheumatoid arthritis and myocardial infarction

Background

Patients with rheumatoid arthritis have an increased risk for accelerated atherosclerosis. It is unknown, however, whether rheumatoid arthritis also increases in-hospital mortality after a myocardial infarction or influences the therapy patients receive.

Methods

A cross-sectional analysis of 1,112,676 patients with myocardial infarction in the 2003-2005 Nationwide Inpatient Sample was performed.

Results

Patients with rheumatoid arthritis were 39% more likely to receive medical therapy (odds ratio [OR], 1.39; 95% confidence interval [CI], 1.30-1.49) than interventional therapy. By using logistic regression, we adjusted for confounding variables to determine the effect of rheumatoid arthritis on the selection of therapy and found that rheumatoid arthritis itself was associated with a 38% increased likelihood of undergoing thrombolysis (OR, 1.38; 95% CI, 1.10-1.71) and a 27% increased likelihood of undergoing percutaneous coronary intervention (OR, 1.27; 95% CI, 1.17-1.39). For the primary outcome measure, we determined that patients with rheumatoid arthritis overall had a 24% better in-hospital mortality compared with other patients with a myocardial infarction (OR, 0.76; 95% CI, 0.68-0.86), which was 34% better after adjusting for confounding variables (OR, 0.66; 95% CI, 0.59-0.74). This better in-hospital mortality was seen in patients with rheumatoid arthritis undergoing medical therapy (adjusted OR, 0.67; 95% CI, 0.59-0.75) and percutaneous coronary intervention (adjusted OR, 0.47; 95% CI, 0.32-0.70), but not in patients undergoing thrombolysis or coronary artery bypass grafting.

Conclusions

Among patients with myocardial infarction, rheumatoid arthritis was associated with an increased use of thrombolysis and percutaneous coronary intervention. Moreover, patients with rheumatoid arthritis had an in-hospital survival advantage, particularly those undergoing medical therapy and percutaneous coronary intervention.     

Safety and efficacy of fondaparinux as an adjunctive treatment to thrombolysis in patients with high and intermediate risk pulmonary embolism

No data are available on the efficacy and safety of a combination of fondaparinux and thrombolysis in the setting of high to intermediate risk pulmonary embolism (PE). Patients submitted to thrombolysis and fondaparinux, presenting with ≥1 of the following criteria were included: (1) cardiogenic shock, (2) syncope, (3) ≥1 proximal thrombo-embolus at CT scan, (4) positive troponin test, (5) echocardiographic findings indicating right ventricular (RV) dysfunction. In-hospital results included death, recurrent PE, persistent RV dysfunction at 48 h echocardiography, bleeding complications. Twenty seven patients were included; 22 received a 2 h infusion of rt-PA and 5 received a 2 h infusion of streptokinase. Ten patients presented with cardiogenic shock (37%), 8 with syncope (30%), all had RV dysfunction. 82% of patients had an uneventful in-hospital course. One patient died during hospital stay from refractory shock. Thrombolysis failed in 2 patients (7%), requiring successful rescue surgical embolectomy. Bleeding events occurred in 2 patients (7%), of whom 1 required blood transfusion. Despite the small sample size, our data suggest that fondaparinux procures adequate tolerability compared to standard current therapy in combination with thrombolysis in high to intermediate risk PE.     

Role of clinical and pulmonary computed tomography angiographic parameters in the prediction of short- and long-term mortality in patients with pulmonary embolism

The utility of pulmonary computed tomography angiography (CTA) in the prediction of short- and long-term outcomes after pulmonary embolism (PE) is controversial. Between November 2011 and September 2014, 190 normotensive patients (age, 61 ± 16.90 years, 53.7 % female) were diagnosed with acute PE using a 128-slice dual-source pulmonary CTA scanner. All the related clinical and cardiovascular measurements were recorded. Primary endpoints were 30-day PE-related death, 30-day composite complications (death, hemodynamic instability, thrombolysis and thrombectomy, inotrope, and mechanical ventilation use), and long-term all-cause mortality during a median follow-up of 14.78 months. Overall 1-month mortality is 5.8 %, and death is PE-related in 4.7 % of total patients. Although non-significant, O₂ saturation <90 % and the right ventricular short-axis to left ventricular short-axis diameters (RV/LV) ratio increase the risk of PE-related death by 3.5 and 2 times, respectively. The independent predictors of 30-day complications (15.8 %) are O₂ saturation <90 % (OR: 3.924, 95 % CI 1.505–10.229), RV/LV ratio (OR: 3.018, 95 % CI 1.455–6.263), and heart rate ≥110 beats/min (OR: 2.607, 95 % CI 1.063–6.391). For long-term mortality (13.7 %), O₂ saturation <90 % is an independent predictor (HR: 4.454, 95 % CI 2.016–8.862). The independent impact of the RV/LV ratio on the long-term mortality has a trend towards statistical significance (HR: 1.762, 95 % CI 0.968–4.218; p value = 0.064). The PE-related death is 4.7 % within 30 days after admisson and 13.7 % after a median follow-up of 14 months. Among the pulmonary CTA parameters, only the RV/LV ratio and among the clinical and paraclinical measures, O₂ saturation <90 % remain independent predictors of short- and long-term mortality and complications after the diagnosis of PE.     

Association of RBC transfusion with mortality in patients with acute lung injury

BACKGROUND: RBC transfusion has been associated with increased morbidity and mortality in a variety of clinical settings. We assessed the effect of RBC transfusion on in-hospital mortality in patients with acute lung injury (ALI). METHODS: Cohort study of 248 consecutive patients with ALI. RBC transfusion was evaluated as both dichotomous and continuous variables, with outcome being in-hospital mortality adjusted for clinical confounders and length of total hospital stay. RESULTS: Overall in-hospital mortality rate was 39.5%. Of these patients, 207 of 248 patients (83.5%) received > or = 1 U of packed RBCs. The transfusion of any packed RBCs was associated with an increased risk of death (adjusted odds ratio [OR], 3.12; 95% confidence interval [CI], 1.28 to 7.58; p < 0.001). The overall OR per unit was 1.06 (95% CI, 1.04 to 1.09; p < 0.001) in the complete multivariable model. Transfusion after ALI onset was associated with an adjusted OR of 1.13 (95% CI, 1.07 to 1.20; p < 0.001), while transfusion before ALI onset was not associated with higher risk. The adjusted OR per unit of nonleukoreduced RBC transfused was 1.14 (95% CI, 1.07 to 1.21; p < 0.001), while the adjusted OR for leukoreduced cells per unit transfused was 1.06 (95% CI, 1.03 to 1.09; p < 0.001). CONCLUSIONS: Transfusion of RBCs in patients with ALI was associated with increased in-hospital mortality. This risk occurred with RBC transfusion after the onset of ALI, and was greater for nonleukoreduced than for leukoreduced RBCs. Aggressive transfusion strategies in patients with established ALI should be questioned, pending further study.     

右室功能异常对血压正常肺栓塞预后影响

目的研究右心室功能异常对血压正常肺栓塞患者临床和预后的影响。方法2001年1月至2004年12月入住本院就诊时血压正常确诊肺栓塞患者,超声心动图检查右室扩张、肺动脉高压作为右室功能异常定量诊断标准。分为血压正常肺栓塞右室功能异常组和正常组,对临床情况进行回顾性分析。结果57例血压正常肺栓塞患者其中27例右室功能异常,30例右室功能正常。右室功能异常组与正常组肺栓塞相关病死率为19％比0％,差异有统计学意义。结论右室功能异常是增加肺栓塞病死率的一个重要因素。超声心动图能较好地评价右室功能状况,可识别出具有高度死亡危险性的人群。     

Association between delayed transthoracic echocardiography and in-hospital mortality in type A acute aortic dissection-associated ST-segment elevated myocardial infarction

BackgroundThis study evaluates the association between transthoracic echocardiography (TTE) timing and in-hospital mortality among individuals presenting with ST-segment elevated myocardial infarction (STEMI) complicating type A acute aortic dissection (TAAAD).MethodsThis cohort study obtained the data of previously published case reports from searches of PubMed (1990–2020), and adults with STEMI secondary to TAAAD were finally included. Delayed TTE (dTTE) exposure was defined as when the TTE test was made available after antithrombotic management for STEMI due to an initially missed diagnosis of TAAAD. The primary outcome of interest was in-hospital mortality, comparing individuals with dTTE and those with emergency TTE (eTTE). The odds ratio (OR) with 95% confidence interval (CI) were calculated to provide an estimate of association.ResultsA total of 109 individuals with a mean age of 56.7 [standard deviation (SD) 12.9] years, and of whom 75 were men (68.8%) presenting with STEMI complicating TAAAD were included. Of all patients, 68 (62.4%) had a dTTE test, which tended to be associated with increased in-hospital mortality after adjustment (OR, 2.320; 95% CI, 0.743–7.248). The association between dTTE and in-hospital death was significant only among patients presenting with a high-risk examination (HRE) (OR, 11.196; 95% CI, 1.322–94.803) and with surgical therapy (OR, 5.375; 95% CI, 1.080–26.700), and not among those presenting with negative HRE (OR, 0.150; 95% CI, 0.016–1.397) and no surgical therapy (OR, 0.177; 95% CI, 0.008–4.018).ConclusionsThis study found an association between dTTE and increased in-hospital mortality in TAAAD-associated STEMI patients with surgical management. This association warrants further investigation.     

Kommentar zu den ESC-Leitlinien ?Guidelines on Diagnosis and Management of Acute Pulmonary Embolism“

As many as 40,000 patients in Germany die of acute pulmonary embolism (PE) each year. The updated (2008) ESC guidelines emphasize the importance of adjusting management strategies to the clinical severity of PE, i.e. the death or complication risk in the acute phase. Haemodynamically unstable patients with suspected high-risk PE should undergo emergency CT pulmonary angiography (CTPA) or, alternatively, echocardiography. If PE is confirmed, thrombolysis or surgical embolectomy should be performed without delay. In normotensive patients (non-high-risk PE), diagnostic algorithms based on multi-detector CTPA are generally preferred. Initial anticoagulation includes low-molecular-weight heparin or fondaparinux. However, selected normotensive patients with right ventricular (RV) dysfunction and/or myocardial injury may benefit from early thrombolysis (intermediate-risk group). Oral anticoagulation for secondary prophylaxis should be continued for at least 3 months. In patients with unprovoked PE, stable INR and low bleeding risk, indefinite anticoagulation may be considered.     

Risk factors for preeclampsia in infertile Chinese women with polycystic ovary syndrome: A prospective cohort study

To explore preconception risk factors for preeclampsia (PE) in women with polycystic ovary syndrome (PCOS), a prospective cohort study was conducted in 92 infertile Chinese women with PCOS who had a singleton pregnancy by ovulation induction and were followed up for 6 weeks after delivery. The patients underwent assessment of physical, endocrine, and metabolic features before ovulation induction. Fifteen (16.3%) patients were diagnosed with PE. Logistic regression analysis showed that preconception sex hormone–binding globulin (SHBG), insulin level at 120 minutes, and body mass index were three independent risk factors for PE (odds ratio [OR], 0.981; 95% confidence interval [CI], 0.964–0.998 [P=.027]; OR, 1.011; 95% CI, 1.000–1.021 [P=.048]; and OR, 1.249; 95% CI, 0.992–1.572 [P=.059], respectively). Receiver operator characteristic analysis indicated the risk value of prepregnancy SHBG, insulin level at 120 minutes, and body mass index (area under the curve=.788, .686, and .697, respectively). Preconception low SHBG levels, overweight/obesity, and hyperinsulinism might be correlated with the subsequent development of PE in patients with PCOS.     

Venous lactate improves the prediction of in-hospital adverse outcomes in normotensive pulmonary embolism

BackgroundArterial lactate is an established risk marker in patients with pulmonary embolism (PE). However, its clinical applicability is limited by the need of an arterial puncture. In contrast, venous lactate can easily be measured from blood samples obtained via routine peripheral venepuncture.MethodsWe investigated the prognostic value of venous lactate with regard to in-hospital adverse outcomes and mortality in 419 consecutive PE patients enrolled in a single-center registry between 09/2008 and 09/2017.ResultsAn optimised venous lactate cut-off value of 3.3 mmol/l predicted both, in-hospital adverse outcome (OR 11.0 [95% CI 4.6–26.3]) and all-cause mortality (OR 3.8 [95%CI 1.3–11.3]). The established cut-off value for arterial lactate (2.0 mmol/l) and the upper limit of normal for venous lactate (2.3 mmol/l) had lower prognostic value for adverse outcomes (OR 3.6 [95% CI 1.5–8.7] and 5.7 [95% CI 2.4–13.6], respectively) and did not predict mortality. If added to the 2019 European Society of Cardiology (ESC) algorithm, venous lactate <2.3 mmol/l was associated with a high negative predictive value (0.99 [95% CI 0.97–1.00]) for adverse outcomes in intermediate-low-risk patients, whereas levels ≥3.3 mmol/l predicted adverse outcomes in the intermediate-high-risk group (OR 5.2 [95% CI 1.8–15.0]).ConclusionVenous lactate above the upper limit of normal was associated with increased risk for adverse outcomes and an optimised cut-off value of 3.3 mmol/l predicted adverse outcome and mortality. Adding venous lactate to the 2019 ESC algorithm may improve risk stratification. Importantly, the established cut-off value for arterial lactate has limited specificity in venous samples and should not be used.     

Clinical risk factors and timing of recurrent venous thromboembolism during the initial 3 months of anticoagulant therapy

BACKGROUND: In patients with venous thromboembolism (VTE), identifying clinical risk factors for recurrence during the initial 3 months of anticoagulant therapy and knowledge of the time course of recurrence may help clinicians decide about the frequency of clinical surveillance and the appropriateness of outpatient treatment. METHODS: Analysis of a randomized controlled trial database involving 1021 patients with VTE (750 with deep vein thrombosis [DVT] and 271 with pulmonary embolism [PE]) who were followed up for 3 months after the start of anticoagulant therapy. All patients received initial treatment with unfractionated heparin or a low-molecular-weight heparin (reviparin) and a coumarin derivative starting the first or second day of treatment, with a target international normalized ratio of 2.0 to 3.0. RESULTS: Four independent clinical risk factors for recurrent VTE were identified: (1) cancer (odds ratio [OR], 2.72; 95% confidence interval [CI], 1. 39-5.32), (2) chronic cardiovascular disease (OR, 2.27; 95% CI, 1. 08-4.97), (3) chronic respiratory disease (OR, 1.91; 95% CI, 0.85-4. 26), and (4) other clinically significant medical disease (OR, 1.79; 95% CI, 1.00-3.21). Older age was associated with a decreased risk for recurrent VTE (OR, 0.76; 95% CI, 0.64-0.92). Previous VTE, sex, and idiopathic VTE were not risk factors for recurrence. In patients with DVT or PE, there was no significant difference in the rates of recurrent nonfatal VTE (4.8% vs 4.1%; P =.62), major bleeding (2.9% vs 2.2%; P =.53), and non-VTE death (6.4% vs 7.8%; P =.45), but recurrent fatal PE was more frequent in patients with PE than DVT (2. 2% vs 0%; P<.01). There was a clustering of recurrent VTE episodes during the initial 2 to 3 weeks after the start of treatment. CONCLUSIONS: During the initial 3 months of anticoagulant therapy, recurrent VTE is more likely to occur in patients with cancer, chronic cardiovascular disease, chronic respiratory disease, or other clinically significant medical disease. Patients with PE are as likely to develop recurrent VTE as those with DVT; however, recurrence is more likely to be fatal in patients who initially present with PE. Arch Intern Med. 2000;160:3431-3436.     

In-hospital and long-term outcome after sub-massive and massive pulmonary embolism submitted to thrombolytic therapy.

BACKGROUND: From a registry of 249 confirmed pulmonary embolism (PE) patients submitted to thrombolytic therapy (TT), we analysed predictors of in-hospital course and long-term mortality. METHODS AND RESULTS: The combined clinical end point of in-hospital course associated death, recurrent PE, repeat thrombolysis, surgical embolectomy or bleeding complications. The long-term follow-up included analysis of survival, and occurrence of PE-related events, defined as recurrent deep vein thrombosis, recurrent PE, occurrence of congestive heart failure or change of New York Heart Association functional class to class III or IV in patients who survived the acute phase.In-hospital clinical course was uneventful in 165 (66.3%) patients. Initial right ventricular (RV) dysfunction was reversible in 80% within 48 h following TT. Initial pulmonary vascular obstruction >70% (RR=5.3 [2.1; 13.6]); haemodynamic instability at presentation (RR=2.6 [1.1; 6]); persistence of septal paradoxical motion after TT (RR=5.9 [1.4; 25.9]); and insertion of intracaval filter (RR=3.7 [1.4; 9.4]) were independent predictors of poor in-hospital course. Mean follow-up was 5.3+/-2.6 years. Of the 227 patients alive after the hospital stay, the probability of survival was 92% at 1 year, 79% at 3 years and 56% at 10 years. Multivariate predictors of long-term mortality were age >75 years (RR=2.73 [2.18; 3.21]; P=0.0002), persistence of vascular pulmonary obstruction >30% after thrombolytic treatment (RR=2.22 [1.69; 2.74]; P=0.003), and cancer (RR=2.03 [1.40; 2.65]; P=0.04). CONCLUSION: The recovery of RV function should be considered as a marker of thrombolysis efficacy, while residual pulmonary vascular obstruction and cancer are independent predictors of long-term mortality. These results advocate the identification of high-risk patients by means of systematic lung-scan and echocardiography pre- and post-thrombolysis, and raise the question of the need for thromboendarterectomy in patients with residual pulmonary vascular obstruction.     

The Drosha rs10719 T>C polymorphism is associated with preeclampsia susceptibility

Purpose: Drosha is a member of the micro RNA (miRNA) processing machinery that affects miRNA processing. Single-nucleotide polymorphisms (SNPs) in the Drosha gene might affect microRNA processing and the expression of various genes. The aim of this study is to investigate the association between SNPs in the Drosha gene and preeclampsia (PE) in the southeast of Iran. Methods: Genotyping of Drosha rs10719 and rs6877842 was performed using blood samples from 219 PE women and 205 healthy control subjects by a polymerase chain reaction-restriction fragment length polymorphism method. Results: The Drosha rs10719TC genotype was significantly associated with 1.6-fold higher risk of PE (odds ratio (OR, 1.6 [95% CI, 1.1–2.4], P = 0.026). In addition, the frequency of the Drosha rs10719CC genotype was significantly higher in PE women and was associated with threefold higher risk of PE (OR 3 [95% CI 1.4–6.3], P = 0.004). There was no association between the Drosha rs6877842 polymorphism and PE susceptibility. The CC–GG combined genotype was associated with 3.4-fold higher risk of PE (OR 3.4 [95% CI 1.4–8.1], P = 0.007). The haplotype-based association analysis showed higher frequency of C–G haplotype of Drosha rs10719 and rs6877842 polymorphisms with the increased risk of PE 1.5-fold (OR 1.5 [95% CI 1.1 – 2], P = 0.01). Conclusions: The Drosha rs10719TC and CC genotypes were associated with PE risk. The CC–GG combined genotype and C–G haplotype of Drosha rs10719 and rs6877842 polymorphisms may increase PE susceptibility.     

Coronary artery bypass grafting in Native Americans: a higher risk of death compared to other ethnic groups?

BACKGROUND: While the efficacy and safety of coronary artery bypass grafting (CABG) has been established in several clinical trials, little is known about its outcomes in Native Americans. MEASUREMENTS AND MAIN RESULTS: We assessed clinical outcomes associated with CABG in 155 Native Americans using a national database of 18,061 patients from 25 nongovernmental, not-for-profit U.S. health care facilities. Patients were classified into five groups: 1) Native American, 2) white, 3) African American, 4) Hispanic, and 5) Asian. We evaluated for ethnic differences in in-hospital mortality and length of stay, and after adjusting for age, gender, surgical priority, case-mix severity, insurance status, and facility characteristics (volume, location, and teaching status). Overall, we found the adjusted risk for in-hospital death to be higher in Native Americans when compared to whites (odds ratio [OR], 3.8; 95% confidence interval [CI], 1.5 to 9.8), African Americans (OR, 3.4; 95% CI, 1.1 to 9.9), Hispanics (OR, 7.1; 95% CI, 2.5 to 20.3), and Asians (OR, 2.8; 95% CI, 1.1 to 7.0). No significant differences were found in length of stay after adjustment across ethnic groups. CONCLUSIONS: The risk of in-hospital death following CABG may be higher in Native Americans than in other ethnic groups. Given the small number of Native Americans in the database (n = 155), however, further research will be needed to confirm these findings.