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Anti-factor Xa as the preferred assay to monitor heparin for the treatment of pulmonary embolism

Zhu, Eric; Yuriditsky, Eugene; Raco, Veronica; Katz, Alyson; Papadopoulos, John; Horowitz, James; Maldonado, Thomas; Ahuja, Tania
INTRODUCTION/BACKGROUND:The mainstay of acute pulmonary embolism (PE) treatment is anticoagulation. Timely anticoagulation correlates with decreased PE-associated mortality, but the ability to achieve a therapeutic activated partial thromboplastin time (aPTT) with unfractionated heparin (UFH) remains limited. Although some institutions have switched to a more accurate and reproducible test to assess for heparin's effectiveness, the anti-factor Xa (antiXa) assay, data correlating a timely therapeutic antiXa to PE-associated clinical outcomes remains scarce. We evaluated time to a therapeutic antiXa using intravenous heparin after PE response team (PERT) activation and assessed clinical outcomes including bleeding and recurrent thromboembolic events. METHODS:This was a retrospective cohort study at NYU Langone Health. All adult patients ≥18 years with a confirmed PE started on IV UFH with >2 antiXa levels were included. Patients were excluded if they received thrombolysis or alternative anticoagulation. The primary endpoint was the time to a therapeutic antiXa level of 0.3-0.7 units/mL. Secondary outcomes included recurrent thromboembolism, bleeding and PE-associated mortality within 3 months. RESULTS:A total of 330 patients with a PERT consult were identified with 192 patients included. The majority of PEs were classified as sub massive (64.6%) with 87% of patients receiving a bolus of 80 units/kg of UFH prior to starting an infusion at 18 units/kg/hour. The median time to the first therapeutic antiXa was 9.13 hours with 93% of the cohort sustaining therapeutic anticoagulation at 48 hours. Recurrent thromboembolism, bleeding and mortality occurred in 1%, 5% and 6.2%, respectively. Upon univariate analysis, a first antiXa <0.3 units/ml was associated with an increased risk of mortality [27.78% (5/18) vs 8.05% (14/174), p = 0.021]. CONCLUSION/CONCLUSIONS:We observed a low incidence of recurrent thromboembolism or PE-associated mortality utilizing an antiXa titrated UFH protocol. The use of an antiXa based heparin assay to guide heparin dosing and monitoring allows for timely and sustained therapeutic anticoagulation for treatment of PE.
PMID: 37989523
ISSN: 1751-553x
CID: 5608542

Need for a Cardiogenic Shock Team Collaborative-Promoting a Team-Based Model of Care to Improve Outcomes and Identify Best Practices

Senman, Balimkiz; Jentzer, Jacob C; Barnett, Christopher F; Bartos, Jason A; Berg, David D; Chih, Sharon; Drakos, Stavros G; Dudzinski, David M; Elliott, Andrea; Gage, Ann; Horowitz, James M; Miller, P Elliott; Sinha, Shashank S; Tehrani, Behnam N; Yuriditsky, Eugene; Vallabhajosyula, Saraschandra; Katz, Jason N
Cardiogenic shock continues to carry a high mortality rate despite contemporary care, with no breakthrough therapies shown to improve survival over the past few decades. It is a time-sensitive condition that commonly results in cardiovascular complications and multisystem organ failure, necessitating multidisciplinary expertise. Managing patients with cardiogenic shock remains challenging even in well-resourced settings, and an important subgroup of patients may require cardiac replacement therapy. As a result, the idea of leveraging the collective cognitive and procedural proficiencies of multiple providers in a collaborative, team-based approach to care (the "shock team") has been advocated by professional societies and implemented at select high-volume clinical centers. A slowly maturing evidence base has suggested that cardiogenic shock teams may improve patient outcomes. Although several registries exist that are beginning to inform care, particularly around therapeutic strategies of pharmacologic and mechanical circulatory support, none of these are currently focused on the shock team approach, multispecialty partnership, education, or process improvement. We propose the creation of a Cardiogenic Shock Team Collaborative-akin to the successful Pulmonary Embolism Response Team Consortium-with a goal to promote sharing of care protocols, education of stakeholders, and discovery of how process and performance may influence patient outcomes, quality, resource consumption, and costs of care.
PMID: 38456417
ISSN: 2047-9980
CID: 5639802

Medical and Mechanical Circulatory Support of the Failing Right Ventricle

Yuriditsky, Eugene; Chonde, Meshe; Friedman, Oren; Horowitz, James M
PURPOSE OF REVIEW/OBJECTIVE:To describe medical therapies and mechanical circulatory support devices used in the treatment of acute right ventricular failure. RECENT FINDINGS/RESULTS:Experts have proposed several algorithms providing a stepwise approach to medical optimization of acute right ventricular failure including tailored volume administration, ideal vasopressor selection to support coronary perfusion, inotropes to restore contractility, and pulmonary vasodilators to improve afterload. Studies have investigated various percutaneous and surgically implanted right ventricular assist devices in several clinical settings. The initial management of acute right ventricular failure is often guided by invasive hemodynamic data tracking parameters of circulatory function with the use of pharmacologic therapies. Percutaneous microaxial and centrifugal extracorporeal pumps bypass the failing RV and support circulatory function in severe cases of right ventricular failure.
PMID: 38108956
ISSN: 1534-3170
CID: 5612422

Catheter-based therapy for intermediate or high-risk pulmonary embolism is associated with lower in-hospital mortality in patients with cancer: Insights from the National Inpatient Sample

Leiva, Orly; Yuriditsky, Eugene; Postelnicu, Radu; Yang, Eric H; Mukherjee, Vikramjit; Greco, Allison; Horowitz, James; Alviar, Carlos; Bangalore, Sripal
BACKGROUND:Pulmonary embolism (PE) is a common complication among patients with cancer and is a significant contributor to morbidity and mortality. Catheter-based therapies (CBT), including catheter-directed thrombolysis (CDT) and mechanical thrombectomy, have been developed and are used in patients with intermediate or high-risk PE. However, there is a paucity of data on outcomes in patients with cancer as most clinical studies exclude this group of patients. AIMS/OBJECTIVE:To characterize outcomes of patients with cancer admitted with intermediate or high-risk PE treated with CBT compared with no CBT. METHODS:Patients with an admission diagnosis of intermediate or high-risk PE and a history of cancer from October 2015 to December 2018 were identified using the National Inpatient Sample. Outcomes of interest were in-hospital death or cardiac arrest (CA) and major bleeding. Inverse probability treatment weighting (IPTW) was utilized to compare outcomes between patients treated with and without CBT. Variables that remained unbalanced after IPTW were adjusted using multivariable logistic regression. RESULTS:A total of 2084 unweighted admissions (10,420 weighted) for intermediate or high-risk PE and cancer were included, of which 136 (6.5%) were treated with CBT. After IPTW, CBT was associated with lower death or CA (aOR 0.54, 95% CI 0.46-0.64) but higher major bleeding (aOR 1.41, 95% CI 1.21-1.65). After stratifying by PE risk type, patients treated with CBT had lower risk of death or CA in both intermediate (aOR 0.52, 95% CI 0.36-0.75) and high-risk PE (aOR 0.48, 95% CI 0.33-0.53). However, patients with CBT were associated with increased risk of major bleeding in intermediate-risk PE (aOR 2.12, 95% CI 1.67-2.69) but not in those with high-risk PE (aOR 0.84, 95% CI 0.66-1.07). CONCLUSIONS:Among patients with cancer hospitalized with intermediate or high-risk PE, treatment with CBT was associated with lower risk of in-hospital death or CA but higher risk of bleeding. Prospective studies and inclusion of patients with cancer in randomized trials are warranted to confirm our findings.
PMID: 37997287
ISSN: 1522-726x
CID: 5608872

Prioritizing Rapid Reperfusion in ST-Segment-Elevation Myocardial Infarction Complicated by Cardiogenic Shock: Leveraging Regionalized Systems of Care [Editorial]

Yuriditsky, Eugene; Horowitz, James M
PMID: 38293832
ISSN: 1941-7632
CID: 5627602

The physiology of cardiac tamponade and implications for patient management

Yuriditsky, Eugene; Horowitz, James M
Exceeding the limit of pericardial stretch, intrapericardial collections exert compression on the right heart and decrease preload. Compensatory mechanisms ensue to maintain hemodynamics in the face of a depressed stroke volume but are outstripped as disease progresses. When constrained within a pressurized pericardial space, the right and left ventricles exhibit differential filling mediated by changes in intrathoracic pressure. Invasive hemodynamics and echocardiographic findings inform on the physiologic effects. In this review, we describe tamponade physiology and implications for supportive care and effusion drainage.
PMID: 38154410
ISSN: 1557-8615
CID: 5623332

The Latest in Resuscitation Research: Highlights From the 2022 American Heart Association's Resuscitation Science Symposium

Stancati, Jennifer A; Owyang, Clark G; Araos, Joaquin D; Agarwal, Sachin; Grossestreuer, Anne V; Counts, Catherine R; Johnson, Nicholas J; Morgan, Ryan W; Moskowitz, Ari; Perman, Sarah M; Sawyer, Kelly N; Yuriditsky, Eugene; Horowitz, James M; Kaviyarasu, Aarthi; Palasz, Joanna; Abella, Benjamin S; Teran, Felipe
BACKGROUND:Every year the American Heart Association's Resuscitation Science Symposium (ReSS) brings together a community of international resuscitation science researchers focused on advancing cardiac arrest care. METHODS AND RESULTS/RESULTS:The American Heart Association's ReSS was held in Chicago, Illinois from November 4th to 6th, 2022. This annual narrative review summarizes ReSS programming, including awards, special sessions and scientific content organized by theme and plenary session. CONCLUSIONS:By exploring both the science of resuscitation and important related topics including survivorship, disparities, and community-focused programs, this meeting provided important resuscitation updates.
PMID: 38038192
ISSN: 2047-9980
CID: 5590452

Feasibility of tele-guided patient-administered lung ultrasound in heart failure

Pratzer, Ariella; Yuriditsky, Eugene; Saraon, Tajinderpal; Janjigian, Michael; Hafiz, Ali; Tsay, Jun Chieh J.; Boodram, Pamela; Jejurikar, Nikita; Sauthoff, Harald
Background: Readmission rates for heart failure remain high, and affordable technology for early detection of heart failure decompensation in the home environment is needed. Lung ultrasound has been shown to be a sensitive tool to detect pulmonary congestion due to heart failure, and monitoring patients in their home environment with lung ultrasound could help to prevent hospital admissions. The aim of this project was to investigate whether patient-performed tele-guided ultrasound in the home environment using an ultraportable device is feasible.Affiliations: Journal instruction requires a country for affiliations; however, these are missing in affiliations [1, 2]. Please verify if the provided country are correct and amend if necessary.Correct Methods: Stable ambulatory patients with heart failure received a handheld ultrasound probe connected to a smart phone or tablet. Instructions for setup were given in person during a clinic visit or over the phone. During each ultrasound session, patients obtained six ultrasound clips from the anterior and lateral chest with verbal and visual tele-guidance from an ultrasound trained clinician. Patients also reported their weight and degree of dyspnea, graded on a 5-point scale. Two independent reviewers graded the ultrasound clips based on the visibility of the pleural line and A or B lines. Results: Eight stable heart failure patients each performed 10"“12 lung ultrasound examinations at home under remote guidance within a 1-month period. There were no major technical difficulties. A total of 89 ultrasound sessions resulted in 534 clips of which 88% (reviewer 1) and 84% (reviewer 2) were interpretable. 91% of ultrasound sessions produced interpretable clips bilaterally from the lateral chest area, which is most sensitive for the detection of pulmonary congestion. The average time to complete an ultrasound session was 5 min with even shorter recording times for the last session. All patients were clinically stable during the study period and no false positive B-lines were observed. Conclusions: In this feasibility study, patients were able to produce interpretable lung ultrasound exams in more than 90% of remotely supervised sessions in their home environment. Larger studies are needed to determine whether remotely guided lung ultrasound could be useful to detect heart failure decompensation early in the home environment.
SCOPUS:85148017423
ISSN: 2524-8987
CID: 5425762

Indigo® Aspiration System for thrombectomy in pulmonary embolism

Raza, Hassan A; Horowitz, James; Yuriditsky, Eugene
Anticoagulation is mainstay therapy for patients with acute pulmonary embolism while systemic thrombolysis is reserved for those with hemodynamic instability. Over the last decade, percutaneous interventional options have entered the landscape aimed to achieve rapid pharmacomechanical pulmonary artery recanalization. The Penumbra Indigo® Aspiration System (Penumbra Inc., CA, USA) is a US FDA-approved large-bore aspiration thrombectomy device for the treatment of pulmonary embolism. Recent data has demonstrated improved radiographic end points with low rates of major adverse events in cases of intermediate-risk pulmonary embolism. In this review article, we outline device technology, applications, evidence and future directions.
PMID: 37746827
ISSN: 1744-8298
CID: 5591032

Chronic thromboembolic pulmonary hypertension and the post-pulmonary embolism (PE) syndrome

Yuriditsky, Eugene; Horowitz, James M; Lau, Joe F
Over a third of patients surviving acute pulmonary embolism (PE) will experience long-term cardiopulmonary limitations. Persistent thrombi, impaired gas exchange, and altered hemodynamics account for aspects of the postpulmonary embolism syndrome that spans mild functional limitations to debilitating chronic thromboembolic pulmonary hypertension (CTEPH), the most worrisome long-term consequence. Though pulmonary endarterectomy is potentially curative for the latter, less is understood surrounding chronic thromboembolic disease (CTED) and post-PE dyspnea. Advances in pulmonary vasodilator therapies and growing expertise in balloon pulmonary angioplasty provide options for a large group of patients ineligible for surgery, or those with persistent postoperative pulmonary hypertension. In this clinical review, we discuss epidemiology and pathophysiology as well as advances in diagnostics and therapeutics surrounding the spectrum of disease that may follow months after acute PE.
PMID: 37036116
ISSN: 1477-0377
CID: 5464052