Pulmonary Embolism – ABC CARDIOL

IJCS

Original Article

Catheter-Directed Therapy for the Management of Intermediate-High-Risk and High-Risk Pulmonary Embolism: Experience from a Single-Centre in Portugal

André Alexandre et al. Bárbara Gonçalves Bruno Brochado David Sá-Couto … Mariana Santos Diana Ribeiro Raquel Baggen-Santos André Luz João Silveira Severo Torres

Abstract

Background:

Acute pulmonary embolism (PE) is a significant cause of morbimortality. Epidemiological data in Portugal are limited, potentially leading to underdiagnosis. Catheter-directed therapy (CDT) is a promising alternative treatment, particularly for high-risk patients.

Objectives:

To evaluate the impact of CDT on intermediate-high-risk and high-risk acute PE.

Methods:

This is a retrospective single-centre study conducted from 2019 to 2023 in Portugal. Data included patient demographics, clinical presentation, procedural characteristics, and outcomes. Comparisons before and after the procedure were carried out, using two-sided paired Student´s T-test or McNemar´s test. P-value < 0.05 was considered statistically significant.

Results:

Among the 21 patients included in this study, the mean age was 62.5 (±16.8) years and 57% (n = 12) were female. Bilateral PE was predominant (n=18, 86%), with fifteen patients (75%) classified as high-risk PE and five (25%) as intermediate-high-risk PE. Overweight (n = 12, 57%), hypertension (n = 9, 45%), dyslipidaemia (n = 8, 40%), immobility (n = 4, 20%), and active cancer (n=3, 14%) were prevalent comorbidities. The median Charlson Comorbidity Index score was 3.5 (IQR 1.2–4.0). Two-thirds (n = 10, 67%) of the patients with high-risk PE exhibited contraindications to systemic fibrinolysis, while one-third (n = 5, 33%) had previously undergone failed thrombolysis. CDT improved hemodynamic parameters, significantly reducing the right ventricular (RV) dysfunction after the procedure (72.2% vs 23.5%, p=0.008). There was a low incidence of bleeding complications, with only one patient (5%) experiencing life-threatening haemorrhage. Despite these improvements, in-hospital mortality remained high (n = 5, 24%). No deaths occurred within three months post-discharge.

Conclusions:

Despite being in its early stages, CDT showed encouraging results in improving hemodynamic and clinical parameters in intermediate-high-risk and high-risk acute PE patients. Larger trials are warranted to further evaluate its efficacy and establish its role in treatment protocols.

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IJCS

Case Report

Massive Pulmonary Embolism After Leg Massage: A Case Report

Stevan Kristian Lionardi et al. Ignatius Ivan Tommy Alexander

Introduction

Venous thromboembolism (VTE) incidents encompass occurrences of both deep vein thrombosis (DVT) and pulmonary embolisms (PE). This occurrence is frequently observed, with an annual incidence rate of 122/100,000 individuals. These two entities share a common pathological pathway, but they are believed to appear in different ways.

In Indonesia, traditional massage is a commonly acknowledged practice applied to individuals experiencing muscle pain or injuries, involving soft tissue manipulation to alleviate pain, induce muscle relaxation, or serve therapeutic purposes as an alternative medical intervention prior to seeking hospital care. Nevertheless, there is limited understanding regarding its effectiveness and safety. Here, we present a case involving a massive PE in a female patient occurring two hours following a traditional lower leg massage, a scenario that has rarely been documented in scientific literature.

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IJCS

Editorial

Rivaroxaban: is it Really Need to Monitor its Anticoagulant Effect in Clinical Practice?

Luiz Eduardo Montenegro Camanho et al. Gustavo Vignoli dos Santos

Oral anticoagulation (OAC) has been the cornerstone for the treatment of atrial fibrillation (AF) patients. The vitamin K antagonist warfarin has been considered the drug of choice in stroke prevention with proven efficacy for more than 60 years. The great inter-patient and intra-patient dose variability and need for routine International Normalized Ratio (INR), are among the main disadvantages of warfarin. The direct-acting oral anticoagulants (DOACs), including direct thrombin inhibitors (dabigatran) and factors Xa inhibitors (apixaban, edoxaban, and rivaroxaban), are currently the therapy of choice for preventing thromboembolic events in patients with atrial fibrillation. Unlike warfarin and other vitamin K antagonists, the DOACs are administered in fixed doses and do not require routine laboratory monitoring.

Rivaroxaban is an oral inhibitor of free and clot-associated factor Xa through reversible, competitive interactions with its active site. Bioavailability following oral administration is dose-dependent, and it is highly bound to plasma proteins. Plasma levels peak 2 to 4 h following oral administration, partially excreted by the kidneys, and has a half-life depending on the dose and age. Factor Xa inhibitors variably affect prothrombin time (PT), with concentration-dependent PT prolongation. The sensitivity of the different assays varies widely, depending on the thromboplastin reagent, and it is recommended to check the sensitivity of PT in each institution. At therapeutic doses, rivaroxaban has a relatively weak effect on PT, but there is a more pronounced effect on supratherapeutic doses.

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IJCS

Case Report

Pulmonary Embolism in Patients with Covid-19 in Direct Oral Anticoagulant

Fabio Augusto De Luca et al. Guilherme Arruda Vinicius Esteves André Feldman … Ítalo Bruno dos Santos Sousa José Célio Vieira Brandão Raquel Muarrek Garcia Olga Ferreira de Souza

Introduction

The global pandemic caused by the new coronavirus (COVID-19) has been promoting major challenges and unprecedented clinical decisions in the medical scenario. Currently, according to the World Health Organization, the disease affects over 185 countries, with over 12 million people infected and nearly 500 thousand deaths.

Among the most serious manifestations of the syndrome, the high prevalence of thromboembolic events, up to 31% of the patients hospitalized in intensive care units, according to an international series, calls attention.^– Different mechanisms of action related to the infection by SARS-CoV-2 may be related to thrombosis: excessive inflammation, tissue hypoxia, immobilization, and disseminated intravascular coagulation (DIC); however, one question remains: Is the etiology linked to some specific effect of the virus or a reflex of the severity of the case? Despite the anticoagulant therapy emerging as a major weapon in the therapeutic arsenal, data is still scarce in the literature regarding the efficacy and safety of warfarin or direct oral anticoagulants (DOAC) in this specific setting. It should be highlighted that, of the 1.5 million people currently infected in Brazil, a significant number present a history of cardiovascular disease and are presently taking anticoagulants. This class of drugs may show serious interactions with investigational therapies currently employed for COVID-19, which could increase the risk of thrombotic or hemorrhagic events. In this context, it becomes imperative to highlight that the thrombosis associated with COVID-19 and anticoagulant therapy is a unique scenario and must be investigated.

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IJCS

Original Article

SAMe-TT2R2 Score: A Useful Tool in Oral Anticoagulation Decision-Making for Venous Thromboembolism Patients?

Fernando Pivatto Júnior et al. Rafaela Fenalti Salla Lísia Cunha Cé Andréia Biolo … André Luís Ferreira Azeredo da Silva Bruno Führ Luís Carlos Amon Marina Bergamini Blaya Rafael Selbach Scheffel

Abstract

Background:

The SAMe-TT₂R₂ score was introduced to identify atrial fibrillation patients with a high risk of not achieving a good time in therapeutic range (TTR) during vitamin K antagonists (VKA) therapy.

Objective:

The aim of this study was to evaluate this score in venous thromboembolism (VTE) patients.

Patients and methods:

A retrospective cohort study of patients receiving care at the outpatient anticoagulation clinic of a tertiary care teaching hospital. Patients were classified as having low (score 0-1) or high risk (score ≥ 2) of not achieving a good TTR. The area under the ROC curve was calculated to assess the ability of the score to predict a TTR ≥ 65%. Adverse event-free survival curves according to the SAMe-TT₂R₂ score were calculated by the Kaplan-Meier method and compared by the log-rank test. A p-value < 0.05 was considered statistically significant.

Results:

We investigated 111 patients during a median follow-up of 2.3 (0.7-6.4) years. Mean age was 54.1 ± 15.7 years and 71 (64.0%) were women. Low- and high-risk groups had similar mean TTR (51.9 vs. 49.6%; p = 0.593). The two groups did not differ significantly in the percentage of patients achieving a TTR ≥ 65% (35.6 vs. 25.8%; p = 0.370). The c-statistic was 0.595 (p = 0.113) for TTR ≥ 65%. Adverse event-free survival during anticoagulation was also similar in both groups (p = 0.136).

Conclusions:

The SAMe-TT₂R₂ score does not seem to be a useful tool in oral anticoagulation decision-making for patients with VTE and should not be used in this setting.

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ABC

Original Article

Fatal pulmonary embolism in hospitalized patients. Clinical diagnosis versus pathological confirmation

Cláudio Tinoco Mesquita et al. José Laerte Boechat Morandi Júnior Flávia Teixeira Perrone Cláudia da Silva Oliveira … Lavínia J. Barreira Sônia Santos C. A Nascimento Raul Carlos Pareto Júnior Evandro Tinoco Mesquita

OBJECTIVE – To assess the incidence of fatal pulmonary embolism (FPE), the accuracy of clinical diagnosis, and the profile of patients who suffered an FPE in a tertiary University Hospital. METHODS – Analysis of the records of 3,890 autopsies performed at the Department of General Pathology from January 1980 to December 1990. RESULTS – Among the 3,980 autopsies, 109 were cases of clinically suspected FPE; of these, 28 cases of FPE were confirmed. FPE accounted for 114 deaths, with clinical suspicion in 28 cases. The incidence of FPE was 2.86%. No difference in sex distribution was noted. Patients in the 6th decade of life were most affected. The following conditions were more commonly related to FPE: neoplasias (20%) and heart failure (18.5%). The conditions most commonly misdiagnosed as FPE were pulmonary edema (16%), pneumonia (15%) and myocardial infarction (10%). The clinical diagnosis of FPE showed a sensitivity of 25.6%, a specificity of 97.9%, and an accuracy of 95.6%. CONCLUSION – The diagnosis of pulmonary embolism made on clinical grounds still has considerable limitations.

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