Diagnosis of pulmonary embolism by acute right heart morphologic and hemodynamic changes observed during exercise stress echocardiography
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Right heart
Transthoracic echocardiogram
Stress Echocardiography
Pulmonary angiography
Computed Tomography Angiography
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Stress Echocardiography
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Pulmonary embolism is major cause of hospital death. Clinical prediction rules such as Wells' prediction rules can help in selection of at-risk patients who need further testing for pulmonary embolism. We evaluated the usefulness of such criteria for detection of patients with diagnosed pulmonary embolism. Patients enrolled in National Research Institute of Tuberculosis and Lung Disease (NRITLD) deep venous thrombosis (DVT) registry were evaluated and those with objective data about presence or absence of pulmonary embolism were selected for this study. Diagnosis of pulmonary embolism was based on computed tomography pulmonary angiography (CTPA). We calculated the embolic burden in those with CTPA-confirmed pulmonary embolism. Eighty-six patients entered the study (58 males, 28 females, mean age = 54.39 ± 1.74 years). Fifty-four cases had coexisting pulmonary embolism (embolic burden score: 10.77 ± 1.181). Embolic burden score was correlated to presence of massive pulmonary embolism (Pearson rho: 0.43, P = 0.002). There was no association between Wells' pulmonary embolism score and the occurrence of pulmonary embolism (Spearman's rho: 0.085, P = 0.51). Dividing the patients into two, or three, risk groups according to Wells' model did not reveal an association with occurrence of pulmonary embolism either (P = 0.99 and P = 0.261, respectively). Tachycardia and hemoptysis were the only parameters from the Wells' pulmonary embolism score correlated to presence of pulmonary embolism (Spearman's rho: 0.373, P < 0.000 and Spearman's rho: 0.297, P = 0.005, correspondingly). Wells' pulmonary embolism score could not predict the occurrence of pulmonary embolism in DVT patients suspected of having coexisting pulmonary embolism. Until further studies shed light on this patient subset, overreliance on Wells' prediction rules as the solo decision making tool should be cautioned.
Pulmonary angiography
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In patients who present with pulmonary embolism, right-heart thrombus is a rare condition that is associated with increased mortality rates, compared with pulmonary embolism alone. Thrombolytic therapy has been associated with a survival benefit in previous studies of pulmonary embolism arising from right-heart thrombus. However, older patients have been excluded from such studies because thrombolysis places them at excessively high risk of bleeding. We present a case, in a 92-year-old woman, of pulmonary embolism arising from right-heart thrombi that we successfully treated with heparin.
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Right heart failure
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Subclinical infection
Right heart failure
Right heart
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Current guidelines suggest treating cancer patients with incidental pulmonary embolism comparably to patients with symptomatic pulmonary embolism. We used the Registro Informatizado de Enfermedad TromboEmbólica (RIETE) registry to compare the rate of major bleeding and symptomatic pulmonary embolism during the course of anticoagulation and after its discontinuation in cancer patients with incidental pulmonary embolism. As of March 2016, 715 cancer patients with incidental pulmonary embolism had been enrolled in RIETE. During the course of anticoagulant therapy (mean 235 days), the rate of major bleeding was higher than the rate of symptomatic pulmonary embolism (10.1 (95% CI 7.48–13.4) versus 3.17 (95% CI 1.80–5.19) events per 100 patient–years, respectively), and the rate of fatal bleeding was higher than the rate of fatal pulmonary embolism (2.66 (95% CI 1.44–4.52) versus 0.66 (95% CI 0.17–1.81) deaths per 100 patient-years, respectively). After discontinuing anticoagulation (mean follow-up 117 days), the rate of major bleeding was lower than the rate of symptomatic pulmonary embolism (3.00 (95% CI 1.10–6.65) versus 8.37 (95% CI 4.76–13.7) events per 100 patient-years, respectively); however, there were no differences in the rate of fatal events at one death each. The risk/benefit ratio of anticoagulant therapy in cancer patients with incidental pulmonary embolism is uncertain and must be evaluated in further studies.
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Background: Stroke is a prominent and financially burdensome disease. Lacunar strokes are traditionally attributed to small vessel disease rather than cardioemboli, which typically occlude larger arteries. Thus, the benefit of screening for potential sources of cardioemboli in lacunar stroke patients is unclear. We evaluated the clinical utility of the transthoracic echocardiogram performed in patients with lacunar strokes. Methods: A single-center retrospective analysis of ischemic stroke patients from January 2013 through December 2017 was performed. Brain magnetic resonance imaging was used to select patients with a single lacunar infarct. Patients presenting with acute symptoms of cardiac disease or an abnormal electrocardiogram were excluded. Transthoracic echocardiogram results were reviewed, and their utility in decision-making was evaluated. Results: Of the 442 patients at our institution diagnosed with ischemic stroke during the inclusion period, 89 met inclusion criteria. Transthoracic echocardiogram detected a patent foramen ovale in 5.6% of patients, mitral annular calcification in 9.0% of patients, and abnormal wall motion in 4.5% of patients. For all patients, there were no findings that prompted anticoagulation, antibiotic, or surgical intervention. The cost of an inpatient transthoracic echocardiogram is $4100, resulting in $364,900 in unnecessary health care spending. Conclusions: Transthoracic echocardiogram appears to have minimal therapeutic value in most patients with lacunar strokes. In stroke patients with no acute symptoms of cardiac disease and a normal electrocardiogram, it may be reasonable to forgo the transthoracic echocardiogram if the brain magnetic resonance imaging shows an isolated lacunar infarct.
Transthoracic echocardiogram
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The appropriate use of echocardiography may reduce the need for invasive diagnostic cardiac procedures.The right side of the heart has recently gained interest among cardiologists as it became clear that abnormalities of the right heart morphology and function are associated with increased morbidity and mortality.Echocardiography is easy to perform, relatively cheap, readily available and do not pose the risk of ionizing radiation.Conventional 2D and, more recently, 3D echocardiography provides pertinent anatomic and physiologic information about the right side of the heart.Because of the advantages and simplicity of echocardiography it continues to be an excellent tool for evaluating the structure and function of the right side of the heart.This review outlines the uses of echocardiography in evaluating the right heart structure and function.
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Abstract Funding Acknowledgements Type of funding sources: None. Introduction Pulmonary hypertension (PH) is the leading cause of death in systemic sclerosis, with a 50% mortality rate within three years of PH diagnosis. The 3-year survival of patients with SSc and PH is estimated to be 56% compared with 94% for those without PH.(1,2). Patients with SSc are at risk of developing group 1 to 3 PH. Detection of PH with echocardiography at rest remains the essential clinical tool; several studies suggested that in patients with SSc, an even earlier change would be the abnormal increase in pulmonary pressures with exercise. (3–6) Purpose Exercise-induced pulmonary hypertension may represent an early but clinically relevant phase in the spectrum of pulmonary vascular disease. On the other hand, increases in mean pulmonary artery pressure on exercise echocardiography can be followed over time, indicating the progression of the pulmonary vascular disease before PH. Methods Observational, prospective, cross-sectional, and analytical study. A basal transthoracic echocardiogram (TTE) and physical stress echocardiogram test were performed, and a TTE follow-up at four years. Results 40 patients. A follow-up was 48 months ED 6 months. Women (93%). Mean age of 49.8 ED 11.4 years. 9.8% of the patients had systemic arterial hypertension; no patient had diabetes mellitus or other chronic-degenerative diseases. 28 (68.3%) patients had the limited cutaneous variety, and 13 (31.7%) patients had the diffuse type. In the basal TTE at the first visit, all had a low probability of presenting pulmonary hypertension; in the follow-up echocardiogram, 11 (26.8%) patients showed a high likelihood of pulmonary hypertension. TTE with a cycle ergometer at first visit: 19 (46.3%) patients presented PSAP >50 mmHg, 16 (39%) patients gave DeltaPSAP >24 mmHg, 19 (46.3%) patients showed a relationship mPAP >30 mmHg + PVR > 3 mmHg/L/min The correlation between stress test variables and the high probability of pulmonary hypertension at follow-up was PSAP>50 mmHg exercise (r 0.58, p<0.001). Delta PSAP >24 mmHg exercise(r 0.40, p 0.011). mPAP>30 mmHg + PVR>3 mmHg/L/min exercises (r 0.45, p 0.003). PVR and >3 mmHg/L/min (r 0.15, p 0.310). Conclusion(s) Exercise-induced pulmonary hypertension is a promising tool in screening patients with systemic sclerosis for the detection of pulmonary hypertension at earlier preclinical stages. Identifying patients with closer follow-up for TTE at rest every 3 to 6 months and not every year as suggested in this disease.
Transthoracic echocardiogram
Stress Echocardiography
Scleroderma (fungus)
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