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Optimal hemodynamic parameters for risk stratification in acute pulmonary embolism patients

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Abstract

Hemodynamic assessment of patients with pulmonary embolism (PE) remains a fundamental component of early risk stratification that in turn, influences subsequent monitoring and therapeutic strategies. The current body of literature and international evidence-based clinical practice guidelines focus mainly on the use of systolic blood pressure (SBP). The accuracy of this single hemodynamic parameter, however, and its optimal values for the identification of hemodynamic instability have been recently questioned by clinicians. For example, abnormal SBP or shock index may be a late indicator of adverse outcomes, signaling a patient in whom the cascade of hemodynamic compromise is already well underway. The aim of the present article is to review the current evidence supporting the use of SBP and analyze the potential integration of other parameters to assess the hemodynamic stability, impending clinical deterioration, and guide the reperfusion treatment in patients with PE, as well as to suggest potential strategies to further investigate this issue.

Graphical Abstract

Hemodynamic assessment, and therefore risk stratification, of patients with pulmonary embolism influences subsequent monitoring and therapeutic strategies. The urgent need arises for the identification of precise hemodynamic parameters, or a set thereof, capable of non-invasively and reliably assessing the hemodynamic condition of patients with pulmonary embolism. These parameters should swiftly identify individuals at higher risk of hemodynamic instability and other immediate and long-term complications, while also facilitating the monitoring of changes in risk status over time

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References

  1. Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, Huisman MV, Humbert M, Jennings CS, Jiménez D, Kucher N, Lang IM, Lankeit M, Lorusso R, Mazzolai L, Meneveau N, Ní Áinle F, Prandoni P, Pruszczyk P, Righini M, Torbicki A, Van Belle E, Zamorano JL, ESC Scientific Document Group (2020) 2019 ESC guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J 41:543–603

    Article  PubMed  Google Scholar 

  2. Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ, Jenkins JS, Kline JA, Michaels AD, Thistlethwaite P, Vedantham S, White RJ, Zierler BK, American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; American Heart Association Council on Peripheral Vascular Disease; American Heart Association Council on Arteriosclerosis, thrombosis and Vascular Biology (2011) Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation 123:1788–1830

  3. Stevens SM, Woller SC, Baumann Kreuziger L, Bounameaux H, Doerschug K, Geersing GJ, Huisman MV, Kearon C, King CS, Knighton AJ, Lake E, Murin S, Vintch JRE, Wells PS, Moores LK (2021) Executive Summary: antithrombotic therapy for VTE Disease: second update of the CHEST Guideline and Expert Panel Report. Chest 160:2247–2259

    Article  PubMed  Google Scholar 

  4. Zuin M, Bikdeli B, Armero A, Porio N, Rigatelli G, Bilato C, Piazza G (2023) Trends in Pulmonary Embolism deaths among young adults aged 25 to 44 years in the United States, 1999 to 2019. Am J Cardiol 202:169–175

    Article  PubMed  Google Scholar 

  5. Zuin M, Bikdeli B, Davies J, Krishnathasan D, Rigatelli G, Roncon L, Bilato C, Piazza G (2023) Contemporary trends in mortality related to high-risk pulmonary embolism in US from 1999 to 2019. Thromb Res 228:72–80

    Article  CAS  PubMed  Google Scholar 

  6. Jiménez D, Bikdeli B, Barrios D, Quezada A, Del Toro J, Vidal G, Mahé I, Quere I, Loring M, Yusen RD, Monreal M, RIETE investigators (2018) Epidemiology, patterns of care and mortality for patients with hemodynamically unstable acute symptomatic pulmonary embolism. Int J Cardiol 269:327–333

    Article  PubMed  Google Scholar 

  7. Secemsky E, Chang Y, Jain CC, Beckman JA, Giri J, Jaff MR, Rosenfield K, Rosovsky R, Kabrhel C, Weinberg I (2018) Contemporary Management and outcomes of patients with massive and submassive pulmonary embolism. Am J Med 131:1506–1514e0

    Article  PubMed  Google Scholar 

  8. Zhao S, Friedman O (2020) Management of right ventricular failure in pulmonary embolism. Crit Clin Care 35:505–515

    Article  Google Scholar 

  9. Kucher N, Rossi E, De Rosa M, Goldhaber SZ (2005) Prognostic role of echocardiography among patients with acute pulmonary embolism and a systolic arterial pressure of 90 mm hg or higher. Arch Intern Med 165:1777–1781

    Article  PubMed  Google Scholar 

  10. Bangalore S, Horowitz JM, Beam D, Jaber WA, Khandhar S, Toma C, Weinberg MD, Mina B (2023) Prevalence and predictors of cardiogenic shock in Intermediate-Risk Pulmonary Embolism: insights from the FLASH Registry. JACC Cardiovasc Interv 16:958–972

    Article  PubMed  Google Scholar 

  11. Zuin M, Rigatelli G, Picariello C, Carraro M, Zonzin P, Roncon L (2017) Prognostic role of a new risk index for the prediction of 30-day cardiovascular mortality in patients with acute pulmonary embolism: the Age-Mean arterial pressure index (AMAPI). Heart Vessels 32:1478–1487

    Article  PubMed  Google Scholar 

  12. Otero R, Trujillo-Santos J, Cayuela A et al (2007) Haemodynamically unstable pulmonary embolism in the RIETE registry. Systolic blood pressure or shock index? Eur Respir J 30:1111–1116

    Article  CAS  PubMed  Google Scholar 

  13. Zuin M, Rigatelli G, Bongarzoni A, Enea I, Bilato C, Zonzin P, Casazza F, Roncon L (2023) Mean arterial pressure predicts 48 h clinical deterioration in intermediate-high risk patients with acute pulmonary embolism. Eur Heart J Acute Cardiovasc Care 12:80–86

    Article  PubMed  Google Scholar 

  14. Chen J, Lin J, Wu D, Guo X, Li X, Shi S (2020) Optimal Mean arterial pressure within 24 hours of admission for patients with Intermediate-Risk and High-Risk Pulmonary Embolism. Clin Appl Thromb Hemost 26:1076029620933944

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. Zuin M, Rigatelli G, Daggubati R, Nguyen T, Roncon L (2020) Impella RP in hemodynamically unstable patients with acute pulmonary embolism. J Artif Organs 23:105–112

    Article  CAS  PubMed  Google Scholar 

  16. Desai PV, Krepostman N, Collins M, De Sirkar S, Hinkleman A, Walsh K, Fareed J, Darki A (2021) Neurological complications of Pulmonary Embolism: a literature review. Curr Neurol Neurosci Rep 21:59

    Article  PubMed  PubMed Central  Google Scholar 

  17. Murgier M, Bertoletti L, Darmon M, Zeni F, Valle R, Del Toro J, Llamas P, Mazzolai L, Villalobos A, Monreal M, RIETE Investigators (2019) Frequency and prognostic impact of acute kidney injury in patients with acute pulmonary embolism. Data from the RIETE registry. Int J Cardiol 291:121–126

    Article  PubMed  Google Scholar 

  18. Aslan S, Meral M, Akku M, Acemoglu H, Ucar EY, Gorguner M, Mirici A (2007) Liver dysfunction in patients with acute pulmonary embolism. Hepatic Res 37:205–213

    Article  CAS  Google Scholar 

  19. Marbach JA, Di Santo P, Kapur NK, Thayer KL, Simard T, Jung RG, Parlow S, Abdel-Razek O, Fernando SM, Labinaz M, Froeschl M, Mathew R, Hibbert B (2022) Lactate Clearance as a surrogate for mortality in cardiogenic shock: insights from the DOREMI Trial. J Am Heart Assoc 11:e023322

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  20. Elder M, Blank N, Kaki A, Alraies MC, Grines CL, Kajy M, Hasan R, Mohamad T, Schreiber T (2018) Mechanical circulatory support for acute right ventricular failure in the setting of pulmonary embolism. J Interv Cardiol 31:518–524

    Article  PubMed  Google Scholar 

  21. Revelly JP, Tappy L, Martinez A, Bollmann M, Cayeux MC, Berger MM, Chiolero RL (2005) Lactate and glucose metabolism in severe sepsis and cardiogenic shock. Crit Care Med 33:2235–2240

    Article  CAS  PubMed  Google Scholar 

  22. Otero R, Trujillo-Santos J, Cayuela A, Rodríguez C, Barron M, Martín JJ, Monreal M, Registro Informatizado de la Enfermedad Tromboembólica (RIETE) Investigators (2007) Haemodynamically unstable pulmonary embolism in the RIETE Registry: systolic blood pressure or shock index? Eur Respir J 30:1111–1116

    Article  CAS  PubMed  Google Scholar 

  23. Zuin M, Rigatelli G, Bilato C, Bongarzoni A, Casazza F, Zonzin P, Roncon L (2022) Prognostic role of serial electrocardiographic changes in patients with acute pulmonary embolism. Data from the Italian Pulmonary Embolism Registry. Thromb Res 217:15–21

    Article  CAS  PubMed  Google Scholar 

  24. Cecconi M, De Backer D, Antonelli M, Beale R, Bakker J, Hofer C, Jaeschke R, Mebazaa A, Pinsky MR, Teboul JL, Vincent JL, Rhodes A (2014) Consensus on circulatory shock and hemodynamic monitoring. Task force of the European Society of Intensive Care Medicine. Intensive Care Med 40:1795–1815

    Article  PubMed  PubMed Central  Google Scholar 

  25. Picone DS, Schultz MG, Otahal P, Aakhus S, Al-Jumaily AM, Black AJ et al (2017) Accuracy of cuff-measured blood pressure: systematic reviews and meta-analyses. J Am Coll Cardiol 70:572–586

    Article  PubMed  Google Scholar 

  26. Geibel A, Zehender M, Kasper W, Olschewski M, Klima C, Konstantinides SV (2005) Prognostic value of the ECG on admission in patients with acute major pulmonary embolism. Eur Respir J 25:843–848

    Article  CAS  PubMed  Google Scholar 

  27. Nielsen TT, Lund O, Rønne K, Schifter S (1989) Changing electrocardiographic findings in pulmonary embolism in relation to vascular obstruction. Cardiology 76:274–284

    Article  CAS  PubMed  Google Scholar 

  28. Zuin M, Rigatelli G, Zonzin P, Casazza F, Roncon L (2018) Short- and long-term prognostic role of diastolic blood pressure in intermediate-high risk patients with acute pulmonary embolism. Eur J Intern Med 55:e23–e24

    Article  PubMed  Google Scholar 

  29. Sheng FQ, Xu R, Xia JD, He MR (2017) ECG patterns indicate severity of Acute Pulmonary Embolism: insights from serial ECG changes in a patient treated with Thrombolysis. J Emerg Med 52:e251–e253

    Article  PubMed  Google Scholar 

  30. Magder S (2018) The meaning of blood pressure. Crit Care 22:257

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  31. Keller K, Beule J, Coldewey M, Dippold W, Balzer JO (2015) Impact of advanced age on the severity of normotensive pulmonary embolism. Heart Vessels 30:647–656

    Article  PubMed  Google Scholar 

  32. Ramos A, Murillas J, Mascías C, Carretero B, Portero JL (2000) Influence of age on clinical presentation of acute pulmonary embolism. Arch Gerontol Geriatr 30:189–198

    Article  CAS  PubMed  Google Scholar 

  33. Jaureguízar A, Jiménez D, Bikdeli B, Ruiz-Artacho P, Muriel A, Tapson V, López-Reyes R, Valero B, Kenet G, Monreal M, Registro Informatizado De La Enfermedad TromboEmbólica investigators (2022) Heart rate and mortality in patients with Acute Symptomatic Pulmonary Embolism. Chest 161:524–534

  34. Aujesky D, Roy PM, Le Manach CP et al (2006) Validation of a model to predict adverse outcomes in patients with pulmonary embolism. Eur Heart J 27:476–481

    Article  PubMed  Google Scholar 

  35. Jiménez D, Aujesky D, Moores L, Gómez V, Lobo JL, Uresandi F, Otero R, Monreal M, Muriel A, Yusen RD, RIETE Investigators (2010) Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism. Arch Intern Med 170:1383–1389

    Article  PubMed  Google Scholar 

  36. Bova C, Vanni S, Prandoni P, Morello F, Dentali F, Bernardi E, Mumoli N, Bucherini E, Barbar S, Picariello C, Enea I, Pesavento R, Bottino F, Jiménez D, Bova Score Validation Study Investigators (2018) A prospective validation of the Bova score in normotensive patients with acute pulmonary embolism. Thromb Res 165:107–111

    Article  CAS  PubMed  Google Scholar 

  37. Hobohm L, Becattini C, Konstantinides SV, Casazza F, Lankeit M (2020) Validation of a fast prognostic score for risk stratification of normotensive patients with acute pulmonary embolism. Clin Res Cardiol 109:1008–1017

    Article  PubMed  PubMed Central  Google Scholar 

  38. Hobohm L, Becattini C, Ebner M, Lerchbaumer MH, Casazza F, Hasenfuß G, Konstantinides SV, Lankeit M (2020) Definition of tachycardia for risk stratification of pulmonary embolism. Eur J Intern Med 82:76–82

    Article  CAS  PubMed  Google Scholar 

  39. Goldhaber SZ, Elliott CG (2003) Acute pulmonary embolism: part I: epidemiology, pathophysiology, and diagnosis. Circulation 108:2726–2729

    Article  PubMed  Google Scholar 

  40. Zuin M, Rigatelli G (2017) Complete heart block as presenting symptom of massive pulmonary embolism in an elderly patient. J Geriatr Cardiol 14:593–594

    PubMed  PubMed Central  Google Scholar 

  41. Klok FA, Piazza G, Sharp ASP, Ní Ainle F, Jaff MR, Chauhan N, Patel B, Barco S, Goldhaber SZ, Kucher N, Lang IM, Schmidtmann I, Sterling KM, Becker D, Martin N, Rosenfield K, Konstantinides SV (2022) Ultrasound-facilitated, catheter-directed thrombolysis vs anticoagulation alone for acute intermediate-high-risk pulmonary embolism: Rationale and design of the HI-PEITHO study. Am Heart J 251:43–53

    Article  CAS  PubMed  Google Scholar 

  42. Jentzer JC, Burstein B, Van Diepen S, Murphy J, Holmes DR Jr, Bell MR, Barsness GW, Henry TD, Menon V, Rihal CS, Naidu SS, Baran DA (2021) Defining shock and preshock for Mortality Risk Stratification in Cardiac Intensive Care Unit patients. Circ Heart Fail 14:e007678

    Article  PubMed  Google Scholar 

  43. Yamashita Y, Morimoto T, Takase T, Hiramori S, Kim K, Oi M, Akao M, Kobayashi Y, Chen PM, Murata K, Tsuyuki Y, Nishimoto Y, Sakamoto J, Togi K, Mabuchi H, Takabayashi K, Kato T, Ono K, Kimura T, COMMAND VTE Registry Investigators (2023) Impact of heart rate at diagnosis on clinical outcomes in patients with Acute Pulmonary Embolism. Am J Cardiol 187:38–47

    Article  PubMed  Google Scholar 

  44. Casazza F, Becattini C, Bongarzoni A, Cuccia C, Roncon L, Favretto G, Zonzin P, Pignataro L, Agnelli G (2012) Clinical features and short term outcomes of patients with acute pulmonary embolism the Italian Pulmonary Embolism Registry (IPER). Thromb Res 130:847–852

  45. Ebner M, Sentler C, Harjola VP, Bueno H, Lerchbaumer MH, Hasenfuß G, Eckardt KU, Konstantinides SV, Lankeit M (2021) Outcome of patients with different clinical presentations of high-risk pulmonary embolism. Eur Heart J Acute Cardiovasc Care 10:787–796

    Article  PubMed  PubMed Central  Google Scholar 

  46. Del Castillo Gordillo C, Avila Cisternas C, Yanez Vidal F, Appiani Florit F, Ibanez Mora A, Van Grieken Garcia J, Mora Valdes R, Luque Gonzales M, Begazo Gonzales A (2010) The relationship between shock index and measures of cardiac output in cardiogenic shock. Eur Heart J Acute Cardiovasc Care 2021. https://doi.org:10:zuab020.172. [Epub Ahead of print]

  47. Houghton D, Jones TW, Cassidy S, Siervo M, MacGowan GA, Trenell MI, Jakovljevic DG (2016) The effect of age on the relationship between cardiac and vascular function. Mech Ageing Dev 153:1–6

    Article  Google Scholar 

  48. Sam A, Sánchez D, Gómez V, Wagner C, Kopecna D, Zamarro C, Moores L, Aujesky D, Yusen R, Jiménez Castro D (2011) The shock index and the simplified PESI for identification of low-risk patients with acute pulmonary embolism. Eur Respir J 37:762–766

    Article  CAS  PubMed  Google Scholar 

  49. Meaney E, Alva F, Moguel R, Meaney A, Alva J, Webe R (2000) Formula and nomogram for the sphygmomanometric calculation of the mean arterial pressure. Heart 84:64

  50. Mathew R, Fernando S, Hu K et al (2022) Optimal perfusion targets in cardiogenic shock. JACC Adv. https://doi.org/10.1016/j.jacadv.2022.100034

    Article  Google Scholar 

  51. Parlow S, Di Santo P, Mathew R, Jung RG, Simard T, Gillmore T, Mao B, Abdel-Razek O, Ramirez FD, Marbach JA, Dick A, Glover C, Russo JJ, Froeschl M, Labinaz M, Fernando SM, Hibbert B, CAPITAL DOREMI investigators (2021) The association between mean arterial pressure and outcomes in patients with cardiogenic shock: insights from the DOREMI trial. Eur Heart J Acute Cardiovasc Care 10:712–720

    Article  PubMed  Google Scholar 

  52. Burstein B, Tabi M, Barsness GW, Bell MR, Kashani K, Jentzer JC (2020) Association between mean arterial pressure during the first 24 hours and hospital mortality in patients with cardiogenic shock. Crit Care 24:513

    Article  PubMed  PubMed Central  Google Scholar 

  53. Chen J, Lin J, Wu D, Guo X, Li X, Shi S (2020) Optimal Mean arterial pressure within 24 hours of admission for patients with Intermediate-Risk and High-Risk Pulmonary Embolism. Clin Appl Thromb Hemost 26:1076029620933944. https://doi.org/10.1177/1076029620933944

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  54. Russell JA (2020) Personalized blood pressure targets in shock: what if your normal blood pressure is low? Am J Respir Crit Care Med 202:10–12

    Article  PubMed  PubMed Central  Google Scholar 

  55. Becattini C, Agnelli G, Maggioni AP, Dentali F, Fabbri A, Enea I, Pomero F, Ruggieri MP, Di Lenarda A, Gulizia M (2022) Contemporary clinical management of acute pulmonary embolism: the COPE study. Intern Emerg Med 17:715–723

    Article  PubMed  PubMed Central  Google Scholar 

  56. Piazza G (2020) Advanced Management of Intermediate- and high-risk Pulmonary Embolism: JACC Focus Seminar. J Am Coll Cardiol 76:2117–2127

    Article  PubMed  Google Scholar 

  57. Hoeper MM, Granton J (2011) Intensive care unit management of patients with severe pulmonary hypertension and right heart failure. AJRCCM 184:1114–1124

    CAS  Google Scholar 

  58. Bavaria R, Stals MAM, Mulder FI, Bistervels IM, Coppens M, Faber LM et al (2023) Use of the National Early warning score for predicting deterioration of patients with acute pulmonary embolism: a post-hoc analysis of the YEARS study. Emerg Med J 40:61–66

    Article  Google Scholar 

  59. Kitsios GD, Dahabreh IJ, Callahan S, Paulus JK, Campagna AC, Dargin JM (2015) Can we trust Observational studies using propensity scores in the critical care literature? A systematic comparison with randomized clinical trials. Crit Care Med 43:1870–1879

    Article  PubMed  Google Scholar 

  60. Li G, Sajobi TT, Menon BK, Korngut L, Lowerison M, James M, Wilton SB, Williamson T, Gill S, Drogos LL, Smith EE, Vohra S, Hill MD, Thabane L (2016) Symposium on Registry-Based Randomized Controlled Trials in Calgary (2016) Registry-based randomized controlled trials- what are the advantages, challenges, and areas for future research? J Clin Epidemio l80:16–24

  61. Doherty DA, Tong SYC, Reilly J, Shrapnel J, McDonald S, Ahern S, Harris I, Tam CS, Brennan AL, Hodgson C, Wilcox L, Balagurunathan A, Butcher BE, Reid CM (2023) Registry randomised trials: a methodological perspective. BMJ Open 13:e068057

    Article  PubMed  PubMed Central  Google Scholar 

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Authors and Affiliations

  1. Department of Translational Medicine, University of Ferrara, Via Aldo Moro 8, Ferrara, 44124, Italy

    Marco Zuin

  2. Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA

    Stanislav Henkin

  3. Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA

    Eileen M. Harder

  4. Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA

    Gregory Piazza

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Contributions

M.Z. and G.P.: Conceptualization, Methodology, Data curation, Validation.: S.H., E.M.H. Writing—original draft. M.Z. Critical revision; G.P., S. H., E.M.H.

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Correspondence to Marco Zuin.

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GP received research grants from BMS/Pfizer, Janssen, Alexion, Bayer, Amgen, BSC, Esperion and 1R01HL164717-01. GP reports an advisory Role for BSC, Amgen, BCRI, PERC, NAMSA, BMS, Janssen, Regeneron. EMH reports research grants from T32-HL0007633 (Brigham and Women’s Hospital, Division of Pulmonary and Critical Care Medicine T32 grant) but has no conflicts of interest. MZ, SH report no potential conflicts of interest.

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Zuin, M., Henkin, S., Harder, E.M. et al. Optimal hemodynamic parameters for risk stratification in acute pulmonary embolism patients. J Thromb Thrombolysis (2024). https://doi.org/10.1007/s11239-024-02998-9

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