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Cardiovascular Medicine
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Schematic of echocardiographic findings in acute pulmonary

embolism. RVOT = right ventricular outflow tract, LVOT = left
ventricular outflow tract, VTI = velocity time integral, RV =
right ventricle, LV = left ventricle, RA = right atrium, LA =
atrium, PA = pulmonary artery, PASP = pulmonary artery
systolic pressure, TV = tricuspid valve, TAPSE = tricuspid
annular systolic exertion, ACT = acceleration time, PFO =
patent foramen ovale (figure was created with
Biorender.com).

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Risk Stratification of Acute Pulmonary Embolism

Article Full-text available
May 2021
Yevgeniy Brailovsky · Sorcha Allen · Dalila
Masic · [...] · Amir Darki
Purpose of review Acute pulmonary embolism (PE) is a
heterogeneous disease process whose presentation
varies widely between individuals who are
asymptomatic, develop cardiogenic shock, or
experience acute PE-related mortality. The purpose of
this review is to summarize the available tools used to
risk stratify patients presenting with acute PE. We...

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... [2][3][4] Accordingly, transthoracic

echocardiographic (TTE) identification of RV
dysfunction is central for risk stratification to guide
acute PE management. 1, 5 Registries provide
crucial information about epidemiology for acute
PE. The Registro Informatizado de la Enfermedad
TromboEmbolica (RIETE) registry 6 is the world's
largest registry on patients with acute venous
thromboembolism (VTE) and provides invaluable
data on acute PE. ...

Validation of Echocardiographic Measurements in

Patients with Pulmonary Embolism in the RIETE…
Registry
Article Full-text available
Jan 2024
Mads Dam Lyhne · Behnood Bikdeli · David M.
Dudzinski · Alfonso Muriel-García · Manuel Monreal
Background In acute pulmonary embolism (PE),
echocardiographic identification of right ventricular (RV)
dysfunction will inform prognostication and clinical…
decision-making. Registro Informatizado Enfermedad
View
TromboEmbolica (RIETE) is the world's largest registry
of patients with objectively confirmed PE. The reliability
of site-reported RV echocardiographic measurements is
unknown. We aimed to validate site-reported key RV
echocardiographic measurements in the RIETE registry.
... ThisFifty-one
study compared
randomlyrisk stratification
patientswith only
Methods chosen in RIETE
whousing the sPESI score. In reality, the(TTE)
sPESIperformed
is part
had transthoracic echocardiogram
of a suite of other tests including rightde-identified
ventricular and
for acute PE were included. TTEs were
(RV) dysfunction on echocardiography, RV/LV
analyzed by a core laboratory of two independent
ratio, hypotension, troponin anddata. BNP/NT-proBNP
observers blinded to site-reported To investigate
levels [29] . These additional factors were not and
reliability, intraclass correlation coefficients (ICCs)
available toplots us with our current dataset and isand a
Bland–Altman between the two observers,
major an limitation ofof
the study. ...
between average the two observers and the RIETE
site-reported data were obtained. Results Core
laboratory interobserver variations were very limited with
Predicting acute and long-term
>0.8 for all mortality in a cohort
correlation coefficients TTE parameters.
of pulmonary wasembolism
substantialpatients
betweenusing machine…
Agreement core laboratory
learning
observers
Article and site-reported
Full-text availabledata for key parameters
including tricuspid annular plane systolic excursion (ICC
Jul 2023 · EUR J INTERN MED[CI], 0.594–0.862) and
0.728; 95% confidence interval
Wahbi K.
pulmonary El-Bouri
arterial · Alexander
systolic pressure Sanders · Gregory
(ICC 0.726; 95% CI,
0.601–0.852).
Y.H. Lip Agreement on right-to-left ventricular
diameter
Background: ratioPulmonary
(ICC 0.739; 95% CI, (PE)
embolism 0.443–1.000)
is a severe was
validated,
condition thatalthough
causes missing data mortality
significant limited the andprecision
morbidity.of
the
Dueestimates.
to its acuteBland–Altman
nature, scores plots
have showed differencest…
been developed
close
stratifytopatients
zero. Conclusion
at high riskWe of showed substantial
30-day mortality. Here we
View
reliability of key RV site-reported measurements in the
develop a machine-learning based score to predict 30-
RIETE registry. Ascertaining the validity
day, 90-day, and 365-day mortality in PE patients. of such data
adds confidence
Methods: and reliability
The Birmingham andforBlacksubsequent
Country Venous
investigations.
Thromboembolism registry (BBC-VTE) of 2183 venous
thromboembolism patients is used. Random forests were
... These models were cohort
based and on clinical
trained on a 70% training tested findings,
against 30%
echocardiography criteria, and cardiac biomarkers
held-out set. The outcomes of interest were 30-day, 90-
day,with
andvarious combinations (3) . were
For example,
365-day mortality. These compared to the
evidence has shown that right ventricular
pulmonary embolism severity index (PESI) and simplified
dysfunction (RVD),severity
detected by echocardiography
pulmonary embolism index (sPESI). Shapley
or biomarkers of myocardial strain (troponins or Oral
values were used to determine important predictors.
BNP), is a critical marker was that may
also indicate a as a
anticoagulation at discharge investigated
severeofand possibly fatal PE and justify more
predictor mortality. Results: The machine learning risk
aggressive treatment (4) . Pulmonary embolism
score predicted 30-day mortality with AUC 0.71 [95% CI:
0.63severity
- 0.78] index (PESI) to & itssPESI
simplified
compared the AUCversion
of 0.65 [95%
(sPESI) is the most validated clinical prognostic
CI: 0.57 - 0.73] and PESI AUC of 0.64 [95% CI: 0.56 -
score, out mortality
of its prognostic classes, PESI classes
0.72]. 90-day and 365-day mortality were
I and II (0-1.6 and 1.7-3.5% 30day mortality risk
predicted with an AUC of 0.74 and 0.73 respectively.
respectively) or sPESI 0white (1.0%blood... cell counts, and
High counts of neutrophils,
c-reactive protein and low counts of haemoglobin were
important for 30-day mortality prediction but
PROGNOSTIC ROLE OF CT with PULMONARY
progressively lost importance time. Older age was
ANGIOGRAPHY IN ACUTE PULMONARY EMBOLISM
an important predictor of high risk throughout.
Conclusion:
Article Machine learning algorithms have improved
on standard clinical risk stratification for PE patients.
Jun 2023
External cohort validation is required before
Ayman Khalifainto
incorporation · Faten Kamel
clinical · Essam AbdEl Hafez ·
workflows.
Amr Amer

View

... Whether AC alone or AC with reperfusion

therapy would suffice mainly depends on the risk
stratification of the PE. [2] [3][4] Recent PE
clinical guidelines stratify the risks and severity of
acute PE based on its clinical presentation and
hemodynamic effects. High-risk PE is defined by
the presence of hemodynamic instability that
includes one of the following clinical
presentations: cardiac arrest, obstructive shock
(systolic blood pressure ,90 mmHg despite an
adequate filling status, in combination with end-
organ hypoperfusion), or persistent hypotension
(systolic blood pressure $40 mmHg for .15 ...

Safety and outcomes of thrombolytic therapy in

patients with pulmonary embolism and…
thrombocytopenia: A systematic review
Article Full-text available
Aug 2022
Fateen Ata · Wanis Hamad Ibrahim ·
Mohammad Nasser Affas · Haseeb Ahmad Khan ·
Balqis Daoudi
Thrombolysis is an established therapeutic modality for
patients with high-risk (and some selected intermediate-
risk) pulmonary embolism (PE) with hemodynamic…
instability. Physicians sometimes experience cases
View
where both a high-risk PE and thrombocytopenia
coexist. Although thrombocytopenia of < 100 × 10³/mm³
is considered a contraindication in patients with ischemic
stroke, the safety and outcomes of thrombolysis in
patients with acute PE and thrombocytopenia are
... Acute PEsystemic
patients are commonly
unknown. This review aimed torisk-stratified
pool data on
with an aim to identify those individuals at in
risk for
the safety and outcomes of thrombolysis use patients
withmorbidity and mortality, so that those
150 who are at a
PE and platelet count less than × 10³/mm³.
low risk to be treated clinical
conservatively or in those at
Patients’ demographics, characteristics,
the highesttype risk treated with escalated
management, of thrombolytic therapy,therapeutic
and
options such as thrombolytic therapy or
outcomes were extracted and analyzed. Of 283 articles
interventional
through methods. 8 Forsearch,
this purpose,
identified the systematic 11 case reports
several institutional guidelines have been
fulfilled the inclusion criteria. The mean age of the
published recently. [9][10]
andHowever, these risk The
patients was 52.27 years, 54.5% were women.
stratification methods arethrombolysis
time consuming
median platelet level before was in 65.50 ×
routine clinical settings and costly. ...
10³/mm³. Before thrombolysis was initiated, the lowest
and highest platelet levels were 29 × 10³/mm³ and 105 ×
10³/mm³, respectively. Alteplase was used in 10 patients
Predictive Role in of Blood Cellular Indices and Their
and urokinase one patient. One patient who had a
Relationship with Endogenous Glycosaminoglyca…
massive PE died of aspiration pneumonia. Interestingly,
as Determinants of Inflammatory Biomarkers in
no thrombocytopenia-related
Article Full-text available complications were
Pulmonary Embolism
reported. This systematic review highlights the potential
benefits and safetyAPPL
Jun 2022 · CLIN THROMB-HEM
of thrombolysis in patients with acute
Bulent
PE in the Kantarcioglu Amir Darki · Nevertheless,
context of thrombocytopenia.
· Fakiha
data
Siddiquiavailable
· in theKrupa
Emily literature concerning
· Jawed Fareedthis topic are
scarce and limited
In thistostudy,
case we reports. More
Introduction: profiled theextensive
levels of blood
studies on the use of thrombolysis in patients with PE
cellular indices, endogenous glycosaminoglycans
and thrombocytopenia arebiomarkers
desperatelyinneeded.
(GAGs) and inflammatory a cohort…
Systematic review registration: The protocol has been
comprised of pulmonary embolism (PE) patients, to
View
registered in the International Prospective Register of
determine their inter-relationships. Identification of this
Systematic
relationship Reviews (PROSPERO): CRD42021286415.
may provide insight to the complex
pathophysiology of PE and the predictive role of blood
cellular indices in acute PE patients. Materials and
methods: Plasma samples from PE patients and healthy
... In these patients' pharmacological thrombus
controls were analyzed for thrombo-inflammatory
breakdown with thrombolytic
IL-6, IL-8,therapy or clotIFN-ɣ,
biomarkers (IL-2, IL-4, IL-10, VEGF,
removal using surgical or EGF,
percutaneous
TNF-α, IL-1α, IL-1β, MCP-1, D-dimer, CRP and
techniques may have great importance for the The
MMP-9) using biochip array and ELISA methods.
outcome. GAG 25 Several institutional guidelines
endogenous levels were quantified using a have
been published in riskmethod.
stratification of acute PE. the
fluorescence quenching The data regarding
26,27 While d-dimer is mostly used as a non-
blood cellular indices were collected through the review
specific biomarker for the diagnosis of VTE, only
of patient medical records and analyzed to demonstrate
theirthe levels of brain natriuretic peptide (BNP) and
relationship. Results: The levels of inflammatory
NT-proBNP, and cardiac troponin andwere lactate have in
biomarkers endogenous GAGs elevated
beenPEvalidated for use in risk prediction (P <of.05).
acute
acute patients compared to controls Most
PE. [28][29][30][31][32][33] More studies are
of the blood cellular indices have shown significant
needed to find a PE better biomarker in diagnosis and (P
differences in acute patients compared to controls
risk The
prediction
levels of of acute PE. ... biomarkers,
< .05). inflammatory
endogenous GAGs and the blood cellular indices have
shown significant associations in correlation and
The Relevance of Anti-PF4 Antibody PLR Isotypes and
multivariable analysis. While NLR, and SII were
Endogenous Glycosaminoglycans and their…
significantly predicting the 30-day mortality, PNR, ELR
Relationship with Inflammatory Biomarkers in
and EMR were
Article not sufficient
Full-text available to predict 30-day mortality
Pulmonary
in acute PE. EmbolismConclusion:Patients Our results show that the
Mar 2022 · CLIN APPL THROMB-HEM
increased thrombo-inflammatory response is associated
Bulent
with theKantarcioglu
release of GAGs · Amir
and theDarki changes
· Fakiha
in blood
cellular indices.
Siddiqui · DebraThe predictive role
Hoppensteadt of theFareed
· Jawed blood cellular
indices for mortality is dependent on their relationship
Introduction Previous studies have shown that
with the inflammatory response.
inflammation may contribute to the interplay of
endogenous glycosaminoglycans (GAGs) and anti-PF…
antibodies. In this study, we quantified the levels of anti-
View
PF4 antibody isotypes and endogenous GAGs together
with inflammatory biomarkers in pulmonary embolism
(PE) patients to determine whether there is a relationship
in between. Identification of this relationship may provide
Breaking Down Barriers in Pursuit of Thrombolytic
insight to the complex pathophysiology of PE and HIT
Perfection
and may also be useful for development of potential
Article
prognostic, diagnostic and therapeutic interventions.
Materials and Methods Plasma samples from PE
Nov 2023
patients (n: 210) were analyzed for anti-PF4 antibody
Yevgeniy
isotypes and Brailovsky · Waqas Ullah
various thrombo-inflammatory cytokines
utilizing
View commercially available biochip array and ELISA
methods. The endogenous GAG levels in PE patients’
plasma were quantified using a fluorescence quenching
method. The collected data analyzed to demonstrate the
relationship
Right-to-leftbetween ventricular various
ratio parameters.
is higher in Results
systole Thethan
endogenous
diastole in patients GAG levels withwereacute increased
pulmonary in the PE group
embolism
( P < .05). The levels of anti-PF4 antibody isotypes were
Articlein varying levels in comparison to the normal
higher
group
Jul 2023 (P< .05). Inflammatory cytokines
· ECHOCARDIOGR-J CARD have shown
varying levels of increase with IL-6, IL-8 and IL-10
Mads Dam Lyhne · David M Dudzinski · Asger
showing the most pronounced values. Mortality outcome
Andersen
was related · Jens Erik Nielsen-Kudsk
to increased GAGs and some · Christopher
of the
Kabrhel
cytokines. Conclusion In this study, we demonstrated
increased levels
Objectives: In acuteof anti-PF4
pulmonary antibody
embolism isotypes,
(PE), the right
endogenous
ventricle (RV)GAGs, may dilate
and inflammatory
compromisingbiomarkers left ventricular
in a
largesize,
(LV) patientthereby
cohort increasing
in PE. The RV/LV
levelsratio.of the End-diastolic…
endogenous
GAGs and
RV/LV ratioinflammatory
is often usedbiomarkers
in PE risk stratification,
were associated though
View
withcause
the PE severity
of death and is mortality.
RV systolic More failure.
studies We are aimed
needed
to
to understand
confirm our pre-clinical
this complex observations
pathophysiology.
of higher RV/LV
ratio in systole compared to diastole in human patients
with PE. Methods: We blinded and independently
Catheter-Directed Thrombolysis or Catheter-Based
analyzed echocardiograms from 606 patients with PE,
Thrombectomy in Acute Pulmonary Embolism
evaluated by a Pulmonary Embolism Response Team.
WeArticle
measured RV/LV ratios in end-systole and end-
diastole and fractional area change (FAC). Our primary
Apr 2023
outcome was a composite of 7-day clinical deterioration,
Phanicharan
treatment escalation Sistla · Kevin
or death. Kheder · Julia Iourinets
Secondary outcomes·
Punit7-day
were Aroraand Amir Darki
· 30-day all-cause mortality. Results:
RV/LV
Venousratio was higher in systole
thromboembolism is a commoncompared to diastole
disorder
(median
encompassing 1.010 [.812-1.256]
both pulmonary vs. .975
embolism[.843-1.149],
(PE) andp deep
<
.0001). RV/LV in (DVT).
vein thrombosis systoleInand thediastole were correlated
United States, up to 2…
(slope
million =people
1.30 [95% CI 1.25-1.35],
are diagnosed with pDVT < .0001 vs. slopewith
and 600,000 =
View
1).
PE RV/LV
annually. ratiosTheinpurpose
both systole of thisand diastole
review is towere
discuss the
associated
indications and with evidence
the primary forcomposite
catheter-directed outcome but not
with all-causeversus
thrombolysis mortality. Conclusion: thrombectomy.
catheter-based The RV/LV ratio is
higher when measured in systole versus in diastole in
Efficacy of PERTacuteCare: Evidence
patients with PE. The two approaches had similar
associations
Chapter with clinical outcomes, that is, it appears
reasonable to measure RV/LV ratio in diastole.
Apr 2023
Yevgeniy Brailovsky · Vladimir Lakhter · Amir
Darki · Geoffrey D. Barnes

View

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