natriuretic-peptide--brain and Venous-Thrombosis

We report the case of a female patient emergently transferred to our institution with the presumptive diagnosis of myocardial infarction in heart failure given the constellation of symptoms and abnormal laboratory cardiac markers on presentation. However, on closer examination, prior to instituting an invasive cardiac work-up, pulmonary embolism was instead strongly considered to explain a common etiology. Therefore, an echocardiogram was promptly obtained, which revealed the presence of McConnell's sign. This noninvasive imaging modality proved to be critical in the prompt recognition and management of this patient. We reviewed the literature regarding the use of echocardiography and the clinical significance of abnormal cardiac markers in patients presenting pulmonary embolism.

Topics: Aged; Diagnosis, Differential; Echocardiography; Electrocardiography; Female; Heart Failure; Humans; Myocardial Infarction; Natriuretic Agents; Natriuretic Peptide, Brain; Pulmonary Embolism; Tibia; Troponin I; Venous Thrombosis

MODALITIES FOR THE DIAGNOSIS OF VENOUS THROMBOEMBOLISM: Currently rely on the confrontation of the initial clinical data and the results of D-dimer measurements, a venous Doppler, although reliable, is not a first-line exploration. REGARDING TREATMENT: Indications for thrombolysis are currently limited to massive pulmonary oedema with shock. Alteplase added to heparin improves the progression of severe embolism; it spares the patients from heavy interventions of resuscitation but the mortality remains the same. Concerning anticoagulant treatments, prolonged antivitamin K at classical doses is more effective than low doses and for limited duration if phlebitis is an idiopathic one. FOR HEART FAILURE WITH PRESERVED EJECTION FRACTION: Treatment of these heart failures, formerly know as 'diastolic' is similar to that of the acute phase of systolic heart failure. However, care should be taken with vasodilatators. CONCERNING HEART FAILURE IN GENERAL: The brain natriuretic peptide (BNP) represents a remarkable progress for the aetiological diagnosis of dyspnoea (inferior to 80 pg/ml in the case of pulmonary origin, superior to 300 pg/ml in the case of cardiac origin or severe pulmonary embolism). Regarding treatment, for acute heart failure, it is still the association of nitrates and diuretics, with oxygen therapy and eventually inotropics. Beta-blockers, which have revolutionized the treatment of chronic heart failure, must be maintained whenever possible in the case of the onset of acute pulmonary oedema. Multisite pacing is increasingly used in refractory chronic heart failure. Implantable defibrillation has become common practice. Non-invasive ventilation (Bi or C-PAP) is interesting in acute cardiogenic pulmonary oedema. THE PREVENTIVE ROLE OF N ACETYL-CYSTEINE: N acetyl cysteine reduces the incidence of nephropathies induced by the radio contrast products in patients with chronic kidney failure. Combined with hydratation, it must be proposed the day before and on the day of the procedure in any patient with diabetes or kidney failure.

Topics: Acetylcysteine; Acute Disease; Adrenergic beta-Antagonists; Anticoagulants; Counterpulsation; Diastole; Diuretics; Echocardiography; Electric Countershock; Fibrin Fibrinogen Degradation Products; Fluid Therapy; Heart Failure; Hemofiltration; Heparin; Humans; Kidney Failure, Chronic; Natriuretic Peptide, Brain; Oxygen Inhalation Therapy; Pulmonary Edema; Thromboembolism; Tissue Plasminogen Activator; Treatment Outcome; Vasodilator Agents; Venous Thrombosis

Among patients hospitalized with acute heart failure (HF), the prognostic value of N-terminal pro-B-type natriuretic peptide (NT-proBNP) in short-term stroke prediction remains unclear.. In the APEX trial, 7513 patients hospitalized for an acute medical illness were randomized to receive either extended-duration betrixaban (80 mg once daily for 35-42 days) or standard-of-care enoxaparin (40 mg once daily for 10 ± 4 days) for venous thromboprophylaxis. Baseline NT-proBNP concentrations were obtained in 3261 patients admitted for HF. Stroke events were adjudicated by an independent clinical events committee blinded to thromboprophylaxis allocation. The association of NT-proBNP level and other risk factors and biomarkers with stroke was assessed at 77 days after randomization.. Baseline NT-proBNP concentration was associated with short-term stroke among patients hospitalized with acute HF. Stroke risk assessment models should consider incorporation of NT-proBNP measurement.

Topics: Acute Disease; Aged; Aged, 80 and over; Benzamides; Enoxaparin; Female; Heart Failure; Hospitalization; Humans; Male; Natriuretic Peptide, Brain; Peptide Fragments; Pyridines; Risk Assessment; Stroke; Venous Thrombosis

Controversy exists about the indication of thrombolytic therapy in the subgroup of hemodynamically stable patients with acute pulmonary embolism (PE) and right ventricular dysfunction. Brain natriuretic peptide (BNP) is excreted from the cardiac ventricles in response to cardiomyocyte stretch and can be measured with an easy-to-perform blood test.. The objective of this study was to determine the predictive value of elevated BNP levels for early recurrent venous thromboembolism with or without fatal outcome in hemodynamically stable patients with acute PE. In addition, we assessed the potential clinical consequences of initiating thrombolytic therapy based on the BNP levels alone.. A nested case-control study was performed within the framework of a large randomized-controlled trial totalling 2213 hemodynamically stable patients with confirmed acute, symptomatic PE. Ninety patients experienced a fatal or non-fatal recurrent venous thromboembolism during the first 3 months of follow-up (cases); Two hundred and ninety-seven patients with uneventful follow-up served as controls. Blood for BNP levels was obtained at referral and assayed in a central laboratory.. Cases had significantly higher mean baseline BNP levels (P = 0.0002). The odds ratio (OR) for every logarithmic (log) unit increase in BNP concentration was 2.4 (95% CI: 1.5-3.7). A BNP cut-off level of 1.25 pmol L(-1) [the optimal point on the receiver-operating characteristic (ROC) curve] was associated with a sensitivity and specificity of 60% and 62%, respectively. In theory, for every patient correctly receiving thrombolytic therapy at this cut-off, 16 patients will receive this therapy unnecessarily.. Brain natriuretic peptide level at presentation is significantly associated with early (fatal) recurrent venous thromboembolism in hemodynamically stable patients with acute PE. However, this relationship appears clinically insufficient to guide the initiation of thrombolytic therapy.

Topics: Acute Disease; Aged; Biomarkers; Fibrinolytic Agents; Humans; Middle Aged; Natriuretic Peptide, Brain; Predictive Value of Tests; Pulmonary Embolism; Risk Factors; Secondary Prevention; Thromboembolism; Thrombolytic Therapy; Venous Thrombosis; Ventricular Dysfunction, Right

Deep vein thrombosis (DVT) is frequently observed in patients with chronic heart failure (CHF), increasing the risk of pulmonary embolism (PE). Clinical evaluation of CHF patients with suspected acute PE is challenging since these diseases share several symptoms and signs such as dyspnea. Thus, it is intuitive that correct and fast diagnosis of PE in these patients might be able to significantly change their clinical outcome. In the present report, we describe a rare case of a patient with CHF and PE due to a huge thrombosis of deep veins and of right atrium in whom echo evaluation permitted the correct diagnosis and therapy.

Topics: Aged; Anticoagulants; Chronic Disease; Echocardiography; Factor Xa Inhibitors; Heart Atria; Heart Failure; Heparin; Humans; Male; Natriuretic Peptide, Brain; Peptide Fragments; Pulmonary Embolism; Thrombosis; Treatment Outcome; Ultrasonography; Venous Thrombosis

Optimal management of acute pulmonary embolism requires expertise offered by multiple subspecialties. As such, pulmonary embolism response teams (PERTs) have increased in prevalence, but the institutional consequences of a PERT are unclear.. We compared all patients that presented to our institution with an acute pulmonary embolism in the 3 years prior to and 3 years after the formation of our PERT. The primary outcome was in-hospital pulmonary embolism-related mortality before and after the formation of the PERT. Sub-analyses were performed among patients with elevated-risk pulmonary embolism.. Between August 2012 and August 2018, 2042 patients were hospitalized at our institution with acute pulmonary embolism, 884 (41.3%) pre-PERT implementation and 1158 (56.7%) post-PERT implementation, of which 165 (14.2%) were evaluated by the PERT. There was no difference in pulmonary embolism-related mortality between the two time periods (2.6% pre-PERT implementation vs 2.9% post-PERT implementation, P = .89). There was increased risk stratification assessment by measurement of cardiac biomarkers and echocardiograms post-PERT implementation. Overall utilization of advanced therapy was similar between groups (5.4% pre-PERT implementation vs 5.4% post-PERT implementation, P = 1.0), with decreased use of systemic thrombolysis (3.8% pre-PERT implementation vs 2.1% post-PERT implementation, P = 0.02) and increased catheter-directed therapy (1.3% pre-PERT implementation vs 3.3% post-PERT implementation, P = 0.05) post-PERT implementation. Inferior vena cava filter use decreased after PERT implementation (10.7% pre-PERT implementation vs 6.9% post-PERT implementation, P = 0.002). Findings were similar when analyzing elevated-risk patients.. Pulmonary embolism response teams may increase risk stratification assessment and alter application of advanced therapies, but a mortality benefit was not identified.

Topics: Aged; Cause of Death; Echocardiography; Embolectomy; Erythrocyte Transfusion; Extracorporeal Membrane Oxygenation; Female; Heart Ventricles; Hemorrhage; Hospital Mortality; Humans; Intracranial Hemorrhages; Length of Stay; Logistic Models; Male; Middle Aged; Natriuretic Peptide, Brain; Patient Care Team; Patient Readmission; Peptide Fragments; Pulmonary Embolism; Referral and Consultation; Thrombolytic Therapy; Tomography, X-Ray Computed; Vena Cava Filters; Venous Thrombosis; Ventricular Dysfunction, Right

Mean platelet volume (MPV) is a risk factor for cardiovascular and inflammatory diseases.. To evaluate the association between high MPV and 90-day mortality after an episode of venous thromboembolism (VTE).. Retrospective cohort of 594 patients with a median age of 73 years (58% women) with a first episode VTE, included in an institutional Thromboembolic Disease registry between 2014 and 2015. MPV values were obtained from the automated blood cell count measured at the moment of VTE diagnosis. Volumes ≥ 11 fL were classified as high. All patients were followed for 90 days to assess survival.. The main comorbidities were cancer in 221 patients (37%), sepsis in 172 (29%) and coronary artery disease in 107 (18%). Median MPV was 8 fl (8-9), brain natriuretic peptide 2,000 pg/ml (1,025-3,900) and troponin 40 pg/ml (19.5-75). Overall mortality was 20% (121/594) during the 90 days of follow-up. Thirty three deaths occurred within 7 days and 43 within the first month. The loss of patients from follow-up was 5% (28/594) at 90 days. Mortality among patients with high MP was 36% (23/63). The crude mortality hazard ratio (HR) for high MPV was 2.2 (95% confidence intervals (CI) 1.4-3.5). When adjusted for sepsis, oncological disease, heart disease, kidney failure and surgery, the mortality HR of high MPV was 2.4 (CI95% 1.5-3.9) in the VTE group, 2.3 (CI95% 1.5-4.4) in the deep venous thrombosis group, and 2.9 (CI95% 1.6 -5.6) in the pulmonary embolism group.. High MPV is an independent risk factor for mortality following an episode of VTE.

Topics: Acute Disease; Aged; Aged, 80 and over; Blood Platelets; Female; Follow-Up Studies; Humans; Male; Mean Platelet Volume; Middle Aged; Natriuretic Peptide, Brain; Neoplasms; Peptide Fragments; Prognosis; Pulmonary Embolism; Retrospective Studies; Risk Assessment; Risk Factors; Sepsis; Survival Analysis; Troponin; Venous Thromboembolism; Venous Thrombosis

Topics: Adrenomedullin; Adult; Aged; Ankle Brachial Index; Anticoagulants; Asymptomatic Diseases; Atrial Fibrillation; Atrial Natriuretic Factor; C-Reactive Protein; Cardiovascular Diseases; Carotid Intima-Media Thickness; Female; Fibrinogen; Germany; Humans; Male; Middle Aged; Natriuretic Peptide, Brain; Peptide Fragments; Phenprocoumon; Protein Precursors; Pulmonary Embolism; Risk Factors; Stroke; Stroke Volume; Vascular Stiffness; Venous Thrombosis; Warfarin

Topics: Blood Pressure; Female; Fibrinolytic Agents; Heart Rate; Humans; Male; Natriuretic Peptide, Brain; Peptide Fragments; Pulmonary Embolism; Recombinant Proteins; Thrombolytic Therapy; Thrombosis; Tissue Plasminogen Activator; Treatment Outcome; Venous Thrombosis

To study the risk factors for acute pulmonary embolism (PE) in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD).. From November of 2009 to May of 2014, 522 admitted patients [aged 42-93 years, mean(72±9)] with AECOPD received CT pulmonary angiography(CTPA) in the First Affiliated Hospital of Guangzhou Medical University. The patients were classified as PE positive (positive result on CTPA) or PE negative (negative results on CTPA), and related risk factors for PE were analyzed.. The frequency of PE was 10.3% in this series of 522 patients with AECOPD. Single factor analysis showed that the following factors were significantly different (χ(2)=4.32-57.06, mean P<0.05)between PE positive and PE negative groups: age≥70 years, immobilization≥3 days, deep vein thrombosis(DVT) and a history of venous thromboembolism(VTE), cor pulmonale caused by COPD, pneumonia, stroke, artery embolization, atrial fibrillation, lower extremity edema, the levels of N-terminal pro-brain natriuretic peptide(NT-proBNP) and D-dimmer. Multiple regression analysis showed that immobilization ≥3 days(OR=25.36, 95%CI: 7.42-86.69, P<0.001), lower extremity edema(OR=7.34, 95%CI: 3.43-15.71, P<0.001) and D-dimmer≥2 000 μg/L(OR=10.10, 95%CI: 2.25-45.42, P=0.003) were the risk factors. The ratio for purulent sputum was 48.1%(26/54) in the PE positive group, and 42.6% (23/54) of the patients showed concurrent purulent sputum and increase of blood markers of infection. The frequency of purulent sputum between PE positive and PE negative groups was not different.. Patients with AECOPD admitted to hospital should be considered for the presence of PE if they had the risk factors of immobilization≥3 days, lower extremity edema and D-dimmer ≥2 000 μg/L.

Topics: Acute Disease; Adult; Aged; Aged, 80 and over; Angiography; Fibrin Fibrinogen Degradation Products; Humans; Middle Aged; Multivariate Analysis; Natriuretic Peptide, Brain; Peptide Fragments; Pulmonary Disease, Chronic Obstructive; Pulmonary Embolism; Pulmonary Heart Disease; Risk Factors; Venous Thromboembolism; Venous Thrombosis

Pulmonary embolism (PE) is an important cause of morbidity and mortality among hospitalized patients. Although the exact epidemiology of PE is not known in India, Some of the studies show that more frequently it is missed and not managed appropriately leading to significant cardiovascular morbidity and mortality. Justification and purpose: Indian guidelines for the diagnosis and treatment of acute PE are not yet formulated. The objective of this consensus statement is to propose a diagnostic and management approach for acute PE in India.. A working group of 15 experts in the management of acute PE (cardiologists, pulmonologist, haematologist, emergency specialist and intensivists). This consensus statement makes recommendations for diagnosis and management for PE based on literature review, including Indian data.

Topics: Acute Disease; Angiography; Anticoagulants; Computed Tomography Angiography; Disease Management; Echocardiography; Electrocardiography; Fibrin Fibrinogen Degradation Products; Humans; India; Natriuretic Peptide, Brain; Peptide Fragments; Perfusion Imaging; Practice Guidelines as Topic; Pulmonary Circulation; Pulmonary Embolism; Radiography, Thoracic; Risk Assessment; Thrombectomy; Thrombolytic Therapy; Troponin I; Troponin T; Vena Cava Filters; Venous Thrombosis

Several factors have been associated with mortality in the months after PE. Factors associated with short-term clinical deterioration or need for hospital-based intervention are less well known.. We prospectively enrolled consecutive emergency department patients with PE and recorded clinical, biomarker and radiographic data. We assessed hospitalised patients daily to identify clinical deterioration or need for hospital-based intervention for 5 days after PE. We captured postdischarge events via 5-day and 30-day interviews. We used univariate and multivariable models to assess associations with clinical deterioration, severe clinical deterioration and 30-day all-cause mortality. We also assessed the test characteristics of three published clinical decision rules.. We enrolled 298 patients with PE: mean age 59 (SD±17) years; 152 (51%) male and 268 (90%) white race. 101 (34%) patients clinically deteriorated or required a hospital-based intervention within 5 days, and 197 (66%) did not. 27 (9%) patients suffered severe clinical deterioration and 12 died within 30 days. Factors independently associated with clinical deterioration were hypotension (p=0.001), hypoxia (p<0.001), coronary disease (p=0.004), residual deep vein thrombosis (p=0.006) and right heart strain on echocardiogram (p<0.001). In contrast, factors associated with 30-day all-cause mortality were active malignancy (p<0.001) and congestive heart failure (p=0.009). The sensitivity of clinical decision rules was moderate (39-80%) for 5-day clinical deterioration but higher (67-100%) for 30-day mortality.. Most patients do not clinically deteriorate after PE diagnosis. Several factors are associated with short-term clinical deterioration, but these factors differ from those associated with 30-day mortality.

Topics: Adult; Aged; Biomarkers; Blood Pressure; Coronary Artery Disease; Decision Support Techniques; Disease Progression; Echocardiography; Female; Heart Failure; Humans; Hypotension; Hypoxia; Male; Middle Aged; Natriuretic Peptide, Brain; Neoplasms; Oxygen; Peptide Fragments; Predictive Value of Tests; Prospective Studies; Pulmonary Embolism; Radiography; Risk Assessment; Risk Factors; ROC Curve; Time Factors; Venous Thrombosis

To investigate the clinical characteristics of inpatients with pulmonary thromboembolism (PTE) and the status of its diagnosis and treatment in different hospitals in Beijing.. The clinical data of the inpatients with PTE from 18 hospitals with different medical levels in Beijing were retrospectively investigated from July 2011 to June 2012. The demographic characteristics, risk factors, clinical manifestations, diagnosis and treatment were recorded and analyzed.. A total of 206 inpatients with PTE were recruited, of whom 53.4% were males, and the mean age was (72 ± 16) years. In terms of the clinical manifestations, 76.2% patients had dyspnea, and 28.6% had lower limb edema. The diagnosis in 86% patients was confirmed by CTPA and 14% by ventilation perfusion scan. Echocardiography was performed in 74.8% patients, screening for deep vein thrombosis. In 81.1% patients, and BNP or NT-proBNP measurements in 57.8% patients. CTNI was tested in 47.6% patients. All patients received anticoagulant therapy, and 8.25% of the patients received thrombolysis. No cases received secondary thrombolysis therapy. 1.5% of the patients received inferior vena cava filter implantation. The main adverse events were bleeding (4.4%) and liver dysfunction (9.2%). The mortality during hospitalization was 2.9%. Compared with tertiary hospitals, the time from admission to diagnosis was shorter, the proportion of intermediate- and high-risk patients was higher in secondary hospitals and fewer patients received lung ventilation perfusion scan.. The status of diagnosis and treatment of inpatient with PTE in hospitals of different medical levels in Beijing is relatively satisfactory, while more attention should be paid to the risk stratification and the identification of etiology.

Topics: Aged; Anticoagulants; Female; Hospitalization; Humans; Inpatients; Lung; Male; Middle Aged; Natriuretic Peptide, Brain; Peptide Fragments; Pulmonary Embolism; Retrospective Studies; Risk Factors; Thrombolytic Therapy; Venous Thrombosis

N-terminal pro-Brain Natriuretic Peptide (NT-pro-BNP) is primarily secreted by left ventricular (LV) stretch and wall tension. Notably, NT-pro-BNP is a prognostic marker in acute pulmonary embolism (PE), which primarily stresses the right ventricle (RV). We sought to evaluate the relative contribution of the RV to NT-pro-BNP levels during PE. A post-hoc analysis of an observational prospective outcome study in 113 consecutive patients with computed tomography (CT)-proven PE and 226 patients in whom PE was clinically suspected but ruled out by CT. In all patients RV and LV function was established by assessing ECG-triggered-CT measured ventricular end-diastolic-volumes and ejection fraction (EF). NT-pro-BNP was assessed in all patients. The correlation between RV and LV end-diastolic-volumes and systolic function was evaluated by multiple linear regression corrected for known confounders. In the PE cohort increased RVEF (β-coefficient (95% confidence interval [CI]) -0.044 (± -0.011); p<0.001) and higher RV end-diastolic-volume (β-coefficient 0.005 (± 0.001); p<0.001) were significantly correlated to NT-pro-BNP, while no correlation was found with LVEF (β-coefficient 0.005 (± 0.010); p=0.587) and LV end-diastolic-volume (β-coefficient -0.003 (± 0.002); p=0.074). In control patients without PE we found a strong correlation between NT-pro-BNP levels and LVEF (β-coefficient -0.027 (± -0.006); p<0.001) although not LV end-diastolic-volume (β-coefficient 0.001 (± 0.001); p=0.418). RVEF (β-coefficient -0.002 (± -0.006); p=0.802) and RV end-diastolic-volume (β-coefficient <0.001 (± 0.001); p=0.730) were not correlated in patients without PE. In PE patients, lower RVEF and higher RV end-diastolic-volume were significantly correlated to NT-pro-BNP levels as compared to control patients without PE. These observations provide pathophysiological ground for the well-known prognostic value of NT-pro-BNP in acute PE.

Topics: Acute Disease; Adult; Aged; Cohort Studies; Contrast Media; Electrocardiography; Female; Heart; Hemodynamics; Humans; Image Processing, Computer-Assisted; Male; Middle Aged; Myocardium; Natriuretic Peptide, Brain; Peptide Fragments; Peptides; Prognosis; Pulmonary Embolism; Regression Analysis; Tomography, X-Ray Computed; Venous Thrombosis; Ventricular Function, Left; Ventricular Function, Right

Massive pulmonary embolism is an uncommon complication of multiple myeloma treated with thalidomide-dexamethasone regimen. In 2006, multiple myeloma was diagnosed in a 72-year-old man, who received thalidomide-dexamethasone therapy. In January 2007, echocardiography and computerized tomography identified massive pulmonary embolism in the pulmonary arteries and a deep vein thrombus of the right leg. The patient also had an elevated concentration of B-type natriuretic peptide. After heparinization and warfarin therapy, the patient's condition improved. This is the first report of a patient with a rare complication of pulmonary embolism from thalidomide-treated multiple myeloma.

Topics: Aged; Antineoplastic Combined Chemotherapy Protocols; Dexamethasone; Humans; Male; Multiple Myeloma; Natriuretic Peptide, Brain; Pulmonary Embolism; Radiography; Thalidomide; Ultrasonography; Venous Thrombosis

Topics: Biomarkers; Clinical Trials as Topic; Fibrinolytic Agents; Humans; Natriuretic Peptide, Brain; Predictive Value of Tests; Pulmonary Embolism; Thromboembolism; Thrombolytic Therapy; Venous Thrombosis; Ventricular Dysfunction, Right