Factors associated with unfavorable long-term prognosis in patients with acute pulmonary embolism
Article Sidebar
Main Article Content
Abstract
The aim – to investigate the possible relation between anamnestic, instrumental, laboratory indicators and venous thromboembolism (VTE) recurrence and bleeding in patients with pulmonary embolism (PE) within 4 months after discharge from the hospital.
Material and methods. The study involved 104 patients with acute PE. Intra-hospital mortality was 13.5 % (14 patients that died were excluded from further analysis). All patients were examined by TTE, 2D STE and venous duplex ultrasound (VDU); indicators were assessed at the first day and after anticoagulant therapy. Anticoagulant therapy was prescribed by envelope method: rivaroxaban or warfarin. VTE recurrence was defined as the appearance of new signs of venous thrombosis according to the data of the VDU and/or computed tomography pulmonary angiography. The assessment of the severity of the bleeding was performed by the TIMI scale.
Results. In the group of patients with recurrent VTE, there were significantly more cases of the observe varicose veins (Р=0.02) with thrombosis localized in the proximal veins (Р=0.03), atrial fibrillation (Р=0.01) and earlier VTE (Р=0.05). Patients in this group were more likely to report hemodynamic disorders: low systolic pressure (Р=0.03), high systolic pulmonary artery pressure (Р=0.03), and segmental fraction of the apical RV segment release less than 65 %, as a sign of right ventricular dysfunction (Р=0.01). The bleedings occurred in 11.1 % of patients during anticoagulant therapy. Among them, there were significantly more patients with arterial hypertension (Р=0.03). In addition, the risk of bleeding is associated with use of drugs, such as streptokinase (Р=0.03) and warfarin (Р=0.03).
Conclusions. VTE reoccurred in 6.7 % (bleeding – 11.1 %) of patients with pulmonary embolism during anticoagulant therapy during 4.2±1.9 months after discharge from hospital. In patients with PE, VTE reoccurrence (regression analysis) is due to the presence of factors (39.6 % (Р<0.05)), such as femoral vein thrombosis (according to VDU), atrial fibrillation, varicose veins, earlier PE episodes; the value of segmental fraction of the apical RV segment release is less than 65 % based on 2D STE. According to regression analysis, the risk of bleeding occurrence is related to the presence of arterial hypertension (8.2 %, Р=0.007), the use of warfarin (8.5 %, Р=0.007) and streptokinase (7.9 %, Р=0.01).
Article Details
Keywords:
References
Целуйко В.Й., Кіношенко К.Ю., Яковлева Л.М., Сухова С.М. Спосіб діагностики дисфункції правого шлуночка при гострій тромбоемболії легеневих артерій.– Патент України на корисну модель № 116337U. МПК (2017.01) А61В 8/00 № u 2016 13385; заявлено 26.12.2016 р, опубл. 10.05.2017.– Бюл. № 9.
Целуйко В.Й., Яковлева Л.М., Кіношенко К.Ю. та ін. Діагностичні можливості 2D-спекл-трекінг ехокардіографії щодо оцінки функції правого шлуночка у хворих з гострою тромбоемболією легеневої артерії // Серце і судини.– 2017.– № 1.– C. 5–11.
ESC Guidelines on the diagnosis and management of acute pulmonary embolism The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology // Eur. Heart J.– 2014.– Vol. 35, N 43.– Р. 3033–3073. doi:10.1093/eurheartj/ehu283
Budaj-Fidecka A., Kurzyna M., Fijałkowska A. et al. In-hospital major bleeding predicts mortality in patients with pulmonary embolism: an analysis of ZATPOL Registry data // Intern. J. Cardiology.– 2013.– Vol. 168, N 4.– Р. 3543–3549. doi: 10.1016/j.ijcard.2013.05.003.
Carrier M., Le Gal G., Wells P.S., Rodger M.A. Systematic review: case-fatality rates of recurrent venous thromboembolism and major bleeding events among patients treated for venous thromboembolism // Ann. Intern. Medicine.– 2010.– Vol. 152, N 9.– Р. 578–589. doi: 10.7326/0003-4819-152-9-201005040-00008.
Cho J.H., Kutti S.G., Kim S.H. et al. Right ventricular dysfunction as an echocardiographic prognostic factor in hemodynamically stable patients with acute pulmonary embolism: a meta-analysis // BMC Cardiovascular Disorders.– 2014.– Vol. 6, N 14.– P. 64–73. doi: 10.1186/1471-2261-14-64.
Donzé J., Le Gal G., Fine M.J. et al. Prospective validation of the Pulmonary Embolism Severity Index. A clinical prognostic model for pulmonary embolism // J. Thromb. Haemostasis.– 2008.– Vol. 100, N 5.– P. 943–948. doi:10.1160/TH08-05-0285
Feigenbaum H. Echocardiography.– Lippincott Williams & Wilkins, 2012.– 785 р.
Goldhaber S.Z., Bounameaux H. Pulmonary embolism and deep vein thrombosis // Lancet.– 2012.– Vol. 379.– Р. 1835 – 1846. doi: 10.1016/S0140-6736 (11)61904-1.
Heit J.A. Epidemiology of venous thromboembolism // Nature Reviews Cardiology.– 2015.– Vol. 12, N 8.– P. 464–474. doi: 10.1038/nrcardio.2015.83
Hofer М. CT Teaching Manual: a systematic approach to CT Reading.– 4th ed.– MEDIDAK Publishing GmbH, 2013.– Р. 367.
Hutten B.A., Prins M.H. Duration of treatment with vitamin K antagonists in symptomatic venous thromboembolism // Cochrane Database Systematic Reviews.– 2014.– Vol. 8.– CD001367. doi: 10.1002/14651858.CD001367.pub3.
Iorio A., Kearon C., Filippucci E. et al. Risk of recurrence after a first episode of symptomatic venous thromboembolism provoked by a transient risk factor: a systematic review // Arch. Intern. Medicine.– 2010.– Vol. 170, N 19.– Р. 1710–1716. doi: 10.1001/archinternmed.2010.367.
Jime´nez D., Aujesky D., Dı´az G. et al. Prognostic significance of deep vein thrombosis in patients presenting with acute symptomatic pulmonary embolism // Amer. J. Respiratory Critical Care.– 2010.– Vol. 181, N 9.– Р. 983–991. doi: 10.1164/rccm.200908-1204OC.
Kasper W., Konstantinides S., Geibel A. et al. Management strategies and determinants of outcome in acute major pulmonary embolism: results of a multicenter registry // J. Amer. Coll. Cardiology – 1997.– Vol. 30, N 5.– Р. 1165 – 171. doi:10.1016/s0735-1097 (97)00319-7.
Kitabatake A., Inoue M., Asao M. et al. Noninvasive evaluation of pulmonary hypertension by a pulsed Doppler technique // Circulation.– 1983.– Vol. 68, N 2.– Р. 302 – 309. PMID: 6861308.
Klok F.A., Hösel V., Clemens A. et al. Prediction of bleeding events in patients with venous thromboembolism on stable anticoagulation treatment // Eur. Respiratory J.– 2016.– Vol. 48, N 5.– Р. 1369–1376. doi: 10.1183/13993003.00280-2016.
Kossaify A. Echocardiographic assessment of the right ventricle, from the conventional approach to speckle tracking and three-dimensional imaging, and insights into the «Right Way» to Explore the Forgotten Chamber // J. Clin. Med. Insig. Cardiology.– 2015.– Vol. 9.– P. 65–75. doi: 10.4137/cmc.s27462.
Laporte S., Mismetti P., Décousus H. et al., RIETE Investigators. Clinical predictors for fatal pulmonary embolism in 15,520 patients with venous thromboembolism: findings from the Registro Informatizado de la Enfermedad TromboEmbolica venosa (RIETE) Registry // Circulation.– 2008.– Vol. 117, N 13.– Р. 1711–1716. doi: 10.1161/circulationaha.107.726232.
Linkins L.A., Choi P.T., Douketis J.D. Clinical impact of bleeding in patients taking oral anticoagulant therapy for venous thromboembolism: a meta-analysis // Ann. Intern. Medicine.– 2003.– Vol. 139.– Р. 893–900. DOI: 10.7326/0003-4819-139-11-200312020-00007.
Lip G.Y. Frison L., Halperin J.L., Lane D.A. Comparative validation of a novel risk score for predicting bleeding risk in anticoagulated patients with atrial fibrillation: the HAS-BLED (Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol Concomitantly) score // J. Amer. Coll. Cardiology.– 2011.– Vol. 57, N 2.– Р. 173–180. doi: 10.1016/j.jacc.2010.09.024.
Mehran R., Rao S.V., Bhatt D.L. et al. Standardized bleeding definitions for cardiovascular clinical trials a consensus report from the bleeding academic research consortium // Circulation.– 2011.– Vol. 123.– Р. 2736–2747. doi: 10.1161/circulationaha.110.009449.
Morris T. Natural history of venous thromboembolism // Critical Care Clinics.– 2011.– Vol. 27.– Р. 869–884. doi: 10.1016/j.ccc.2011.09.001.
Prandoni P., Lensing A.W., Piccioli A. et al. Recurrent venous thromboembolism and bleeding complications during anticoagulant treatment in patients with cancer and venous thrombosis // Blood.– 2002.– Vol. 100, N 10.– Р. 3484–3488. doi: 10.1182/blood-2002-01-0108.
Ribeiro A., Lindmarker P., Johnsson H. et al. Pulmonary embolism: one-year follow-up with echocardiography doppler and five-year survival analysis // Circulation.– 1999.– Vol. 99, N 10.– Р. 1325–1330.
Schück O., Smrcková J., Teplan V. et al. A new method to estimate glomerular filtration rate based on serum concentration of creatinine, urea and albumin (MDRD, Modification of Diet in Renal Disease) // Vnitřní lékařství.– 2004.– Vol. 50, N 7.– P. 507–509. PMID: 15323257.
Sekhri V., Mehta N., Rawat N. et al. Management of massive and nonmassive pulmonary embolism // Arch. Med. Science.– 2012.– Vol. 8, N 6.– P. 957–969. doi:10.5114/aoms.2012.32402.
Tagalakis V., Patenaude V., Kahn S.R., Suissa S. Incidence of and mortality from venous thromboembolism in a real-world population: the Q-VTE Study Cohort // Amer. J. Medicine.– 2013.– Vol. 126, N 9.– Р. 832–833. doi: 10.1016/j.amjmed.2013.02.024.
Tovey C., Wyatt S. Diagnosis, investigation, and management of deep vein thrombosis Clinical review // Brit. Med. J.– 2003.– Vol. 26.– Р. 1180–1184. doi:10.1136/bmj.326.7400.1180.
Van der Hulle T., Kooiman J., den Exter P.L. et al. Effectiveness and safety of novel oral anticoagulants as compared with vitamin K antagonists in the treatment of acute symptomatic venous thromboembolism: a systematic review and meta-analysis // J. Thromb. Haemostasis.– 2014.– Vol. 12, N 3.– Р. 320–328. doi: 10.1111/jth.12485.
Zierler B.K. Ultrasonography and diagnosis of venous thromboembolism. // Circulation.– 2004.– Vol. 109, N 12 (Suppl. 1).– Р. 9–14. doi:10.1161/01.cir.0000122870.22669.4a.