Journal Feed Weekly Wrap-Up

We always work hard, but we may not have time to read through a bunch of journals. It’s time to learn smarter. 

Originally published at JournalFeed, a site that provides daily or weekly literature updates. 

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#1: Interventional Therapies for Acute PE – What We Know and What We Don’t

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Emergency medicine docs should understand risk stratification of patients with acute PE as well as the risks, benefits, and gaps in evidence associated with interventional therapies.

Why does this matter?
The advent of catheter-directed lysis (CDL), catheter-based embolectomy, and the incorporation of a Pulmonary Embolism Response Team (PERT) are new, dynamic, interventional considerations for the management of massive PE as well as the more heavily debated intermediate-risk PE.

There is a LOT here. Let’s make like a lytic and break this down.

Risk Stratification
PE severity is divided into three main categories:

  1. Massive – hypotension (<90mmHg, but don’t forget “a drop of SBP >40mmHg for 15 min” counts)

  2. Submassive – no hypotension, but RV strain by echo, CT, or biomarkers (new ESC guidelines break this class into Intermediate-Low Risk and Intermediate-High Risk dependent on PESI score and elevation of troponin + RV dysfunction)

  3. Low Risk – not submassive. Low PESI score. Consider discharge home.

-Current risk stratification schemes have not been shown to improve patient outcomes.
-Most challenging is the intermediate-risk subgroup.
-Intermediate-risk PE patients at increased risk of decompensation include those with: elevated PESI or simplified PESI scores, severe PE-related functional impairment, and objective signs of severely diminished end-organ perfusion or stroke volume. Assuming low bleeding risk, such patients may benefit from thrombolysis or CDL.

CDL – catheter directed lysis

  • Current interventional therapies for acute PE include CDL or catheter-based embolectomy. Two devices: EKOSonic and FlowTriever have been cleared by the FDA for use in acute PE.

  • Use of CDL or catheter-based embolectomy in patients with intermediate-risk PE has, thus far, been correlated only with more rapid improvement of RV dysfunction than anticoagulation alone, not short- or long-term clinical or functional outcomes. CDL v. systemic thrombolysis is unknown.

  • Risks and benefits of systemic thrombolysis are closely counterbalanced in the intermediate-risk PE subgroup. Further, optimal dose and duration of systemic thrombolysis are unknown.

  • Indirect evidence supports lower rates of ICH and major bleeding in CDL compared to systemic thrombolysis.

  • No data support prevention of recurrent PE with CDL for treatment of acute PE.

Post-PE syndrome and chronic thromboembolic pulmonary hypertension (CTEPH)

  • A subset of patients with PE develop persistent symptoms and functional limitations; it is uncertain if systemic thrombolysis or CDL are associated with decreased post-PE syndrome.

  • It is unknown if CDL or embolectomy reduces the incidence of CTEPH.

Future Research Considerations

  • Effectiveness outcomes should include traditional clinical outcomes (death, hemodynamic decompensation, development of CTEPH) and patient-centered functional or quality of life measures.

  • Surrogate end points, including the short-term reduction in RV/LV ratio, should not be a proxy for mortality or other clinical outcomes in studies of patients with intermediate-risk PE.

PERT – PE Response Team

  • Available data demonstrate the use of CDL in 10-20% of patients with intermediate-risk PE.

  • Data on the influence of PERTs on the use of catheter-directed embolectomy are limited, but the use of CDL in hospitals with PERTs appears to be more common than the use of systemic thrombolysis.

  • It is unclear whether the PERT framework for acute PE care improves patient outcomes and is cost-effective.

Another Spoonful

Giri, J., et al., Interventional Therapies for Acute Pulmonary Embolism: Current Status and Principles for the Development of Novel Evidence: A Scientific Statement From the American Heart Association. Circulation, 2019. 140(20): p. e774-e801.

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#2: FAINT Score – Who Needs Admission For Syncope?

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For elderly patients presenting after syncope, the FAINT Score, a 5-variable risk score, predicted serious 30-day outcomes, although the rule has not had external validation.

Why does this matter?
Syncope is common and potentially serious. There has yet to be a risk stratification tool that has gained widespread adoption or validation, making disposition challenging. We covered use of biomarkers for syncope risk stratification earlier as standalone predictors. How would using biomarkers as part of a broader risk score fare?

Torturing acrostics is inhumane…
This was a prospective, observational study of 3,177 adults over the age of 60 with unexplained syncope or near syncope from 11 EDs in the U.S. Patients with a newly identified serious diagnosis were excluded. The authors used Bayesian logistic regression to derive the variables and came up with the tortured acrostic: the FAINT Score:

F: Heart failure (1 point)
A: Cardiac arrhythmia (1 point)
I: Initial abnormal EKG (1 point)
N: elevated B-type natriuretic peptide (2 points)
T: elevated high sensitivity troponin T (1 point)

A FAINT score of 0 versus ≥1 had a sensitivity of 96.7% (95 CI 92.9-98.8%) and specificity 22.2% (95% CI 20.7-23.8%) for excluding death and serious cardiac outcomes at 30 days. The FAINT score was almost more accurate than unstructured physician judgment (AUC 0.704 vs 0.630). I will not be using the FAINT score, as it has yet to be externally validated and uses two high sensitivity biomarkers (NT-proBNP and hs-cTnT) not readily available in all emergency departments. However, it is simple and uses practical variables, and it will be interesting to see if it holds up to external validation, unlike so many of its predecessors.

Another Spoonful
Check out this podcast by Emergency Medicine Cases for a thorough review of literature on adult and pediatric syncope.

Risk Stratification of Older Adults Who Present to the Emergency Department With Syncope: The FAINT Score. Ann Emerg Med. 2019 Oct 23. pii: S0196-0644(19)31113-8. doi: 10.1016/j.annemergmed.2019.08.429. [Epub ahead of print]

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#3: IV TXA for Hemoptysis

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Intravenous tranexamic acid (TXA) may reduce in-hospital mortality, length of stay, and total healthcare costs for patients admitted with hemoptysis.

Why does this matter?
Hemoptysis is a sphincter tightening disease associated with significant morbidity and mortality.  Management of hemoptysis consists primarily of interventional procedures to stop hemorrhage. There are few medical treatment options. Inhaled (TXA) has recently shown promise. How about IV TXA?

TXA: A Panacea for Hemoptysis?
This was a retrospective observational study of 28,539 patients from Japan comparing in-hospital mortality for patients with hemoptysis who received IV TXA on the day of hospital admission to those that did not.  After propensity score matching two groups with 9,933 patients each, administration of IV TXA was associated with lower in-hospital mortality (11.5% vs. 9.0%; p < 0.001), shorter hospital stay (18 ± 24 days vs. 16 ± 18 days; p < 0.001), and lower total healthcare costs ($7,573 ± 10,085 vs. $6,757 ± 9,127; p < 0.001). Adverse effects such as venous thromboembolism and seizure were rare and not significantly increased in the TXA group. Limitations include the retrospective and observational nature of the study, possible unmeasured confounders, and patient crossover among the treatment groups. In addition, the time from symptom onset to the initiation of TXA was not measured, and the temporal effect of TXA for patients with hemoptysis is currently unknown. Nevertheless, this study suggests that IV TXA may be a cost effective and safe therapy that could decrease mortality for patients with hemoptysis. TXA may not be a panacea for hemoptysis, but both IV and inhaled TXA may be useful adjuncts for a serious disease with few other proven medical therapies.

Effect of tranexamic acid on mortality in patients with haemoptysis: a nationwide study. Crit Care. 2019 Nov 6;23(1):347. doi: 10.1186/s13054-019-2620-5.

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