Publications by authors named "Paul D Stein"

176 Publications

Nineteen-Year Trends in Mortality of Patients Hospitalized in the United States with High-Risk Pulmonary Embolism.

Am J Med 2021 Feb 22. Epub 2021 Feb 22.

Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing.

Background: Several advanced treatments of high-risk patients with pulmonary embolism have been used in recent decades. We assessed the 19-year national trend in mortality of high-risk patients with pulmonary embolism to determine what impact, if any, advanced therapy might have had on mortality.

Methods: Mortality (case fatality rate) was assessed in patients with a primary (first-listed) diagnosis of high-risk pulmonary embolism who were hospitalized during the period from 1999 to 2014 and in 2016 and 2017. High-risk was defined as patients with pulmonary embolism who were in shock or suffered cardiac arrest. International Classification of Diseases, 9th revision, Clinical Modification codes were used for data on the period from 1999 to 2014, and version 10 codes were used for data on the years 2016 and 2017. Trends in mortality were assessed according to treatment.

Results: From 1999 to 2017 (excluding 2015), 58,784 patients were hospitalized in United States with a primary diagnosis of pulmonary embolism that was high risk. Mortality in all high-risk patients decreased from 72.7% in 1999 to 49.8% in 2017 (P < .0001). Most high-risk patients (60.3%) were treated with anticoagulants alone and did not receive an inferior vena cava filter. Mortality in these patients decreased from 79.0% in 1999 to 55.7% in 2017 (P < .0001). Thrombolytic therapy was administered to 16.1% of high-risk patients, open pulmonary embolectomy alone was used in 4.3%, and extracorporeal membrane oxygenation was used in 0.4%.

Conclusions: Mortality of high-risk patients with pulmonary embolism has decreased. This decrease can be attributed to improved treatment of patients with shock and with cardiac arrest, and does not reflect advances in therapy for pulmonary embolism.
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http://dx.doi.org/10.1016/j.amjmed.2021.01.026DOI Listing
February 2021

Usefulness of ancillary findings on CT pulmonary angiograms that are negative for pulmonary embolism.

Thromb Res 2021 Apr 26;200:48-50. Epub 2021 Jan 26.

Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, United States of America; Department of Emergency Medicine, Sparrow Health System, East Lansing, MI, United States of America.

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http://dx.doi.org/10.1016/j.thromres.2021.01.018DOI Listing
April 2021

Site of Deep Venous Thrombosis and Age in the Selection of Patients in the Emergency Department for Hospitalization Versus Home Treatment.

Am J Cardiol 2021 May 30;146:95-98. Epub 2021 Jan 30.

Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan.

Despite apparent advantages of home treatment of deep venous thrombosis (DVT) based upon results of randomized controlled trials, physicians maintain a conservative approach, and a large proportion of patients with DVT are hospitalized. In the present investigation we assess whether selection of patients for hospitalization for acute DVT was related to the site of the DVT or to age. This was a retrospective cohort study based on administrative data from the Nationwide Emergency Department Sample, 2016. Patients were identified by International Classification of Diseases-10-Clinical Modification codes. Most, 87,436 of 133,414 (66%), had proximal DVT. A minority of patients with isolated distal DVT were hospitalized, 10,621 of 37,592 (28%). However, hospitalization was selected for 47,459 of 87,436 (54%) with proximal DVT; 4,867 of 7,599 (64%) with pelvic vein DVT; and 611 of 788 (78%) with DVT involving the inferior vena cava. Hospitalization for patients with distal DVT, proximal DVT, and pelvic vein DVT was age-dependent. In conclusion, both the site of acute DVT and age were factors affecting the clinical decision of emergency department physicians to select patients for hospital treatment.
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http://dx.doi.org/10.1016/j.amjcard.2021.01.024DOI Listing
May 2021

In-Hospital Risks and Management of Deep Venous Thrombosis According to Location of the Thrombus.

Am J Med 2020 Dec 11. Epub 2020 Dec 11.

Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing.

Background: Whether deep venous thrombosis involving the pelvic veins or inferior vena cava is associated with higher in-hospital mortality or higher prevalence of in-hospital pulmonary embolism than proximal or distal lower extremity deep venous thrombosis is not known.

Methods: This was a retrospective cohort study based on administrative data from the Nationwide Inpatient Sample, 2016, 2017. Patients hospitalized with a primary diagnosis of deep venous thrombosis at known locations were identified by International Classification of Diseases-10-Clinical Modification codes.

Results: In-hospital all-cause mortality with deep venous thrombosis involving the inferior vena cava in patients treated only with anticoagulants was 2.2% versus 0.8% with pelvic vein deep venous thrombosis (p<0.0001), 0.7% with proximal deep venous thrombosis (p<0.0001) and 0.2% with distal deep venous thrombosis (p<0.0001).  Mortality with anticoagulants was similar with pelvic vein deep venous thrombosis compared with proximal lower extremity deep venous thrombosis, 0.8% versus 0.7% (p=0.39). Lower mortality was shown with pelvic vein deep venous thrombosis treated with thrombolytics than with anticoagulants, 0% versus 0.8% (p<0.0001). In-hospital pulmonary embolism occurred in 11% to 23%, irrespective of the site of deep venous thrombosis.

Conclusion: Patients with deep venous thrombosis involving the inferior vena cava had higher in-hospital mortality than patients with deep venous thrombosis at other locations. Pelvic vein deep venous thrombosis did not result in higher mortality or more in-hospital pulmonary embolism than proximal lower extremity deep venous thrombosis.  The incidence of in-hospital pulmonary embolism was considerable with deep venous thrombosis at all sites.
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http://dx.doi.org/10.1016/j.amjmed.2020.11.013DOI Listing
December 2020

Hospitalizations for High-Risk Pulmonary Embolism.

Am J Med 2020 Nov 24. Epub 2020 Nov 24.

Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing.

Background: The incidence of pulmonary embolism has been increasing. It has been suggested that this may reflect overdiagnosis due to widespread use of computed tomographic pulmonary angiography. The purpose of the present investigation is to further evaluate whether the increasing incidence of pulmonary embolism represents overdiagnosis.

Methods: This was a retrospective cohort study based on administrative data from the National (Nationwide) Inpatient Sample 1999-2014. International Classification of Diseases, Ninth Revision, Clinical Modification codes were used. The population of the United States according to year was determined from the Centers for Disease Control and Prevention.

Results: The incidence of pulmonary embolism increased from 65/100,000 population in 1999 to 137/100,000 population in 2014 (P < .0001). High-risk pulmonary embolism increased from 2.2/100,000 population to 9.9/100,000 population (P < .0001). The incidence of primary pulmonary embolism increased from 40/100,000 population in 1999 to 73/100,000 population in 2014 (P < .0001). High-risk pulmonary embolism in patients with a primary diagnosis of pulmonary embolism increased from 0.8/100,000 population in 1999 to 2.3/100,000 population in 2014 (P < .0001). Among patients with pulmonary embolism, the incidence of high-risk pulmonary embolism increased from 1999-2014 (P = .0025). In-hospital all-cause mortality in high-risk patients was 102,402 of 195,909 (52.2%).

Conclusions: The incidence of high-risk pulmonary embolism has increased concordantly with the increasing incidence of all pulmonary embolism. Increasing proportions of patients with potentially lethal pulmonary embolism are being diagnosed.
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http://dx.doi.org/10.1016/j.amjmed.2020.10.029DOI Listing
November 2020

Effects of Thrombolytic Therapy in Low-Risk Patients With Pulmonary Embolism.

Am J Cardiol 2021 01 28;139:116-120. Epub 2020 Sep 28.

Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan.

We performed this investigation to determine the effects on mortality of thrombolytic therapy in low-risk patients with pulmonary embolism (PE). This was a retrospective cohort study based on administrative data from the Nationwide Inpatient Sample, 2016 and 2017. Patients with a primary (first-listed) diagnosis of acute PE who were not in shock and not on a ventilator who did not have acute cor pulmonale were defined as low-risk. Patients were identified by International Classification of Diseases-10-Clinical Modification Codes. Mortality was assessed according to treatment with catheter-directed thrombolysis, intravenous thrombolytic therapy, or anticoagulants alone. Mortality with inferior vena cava (IVC) filters was also assessed. Mortality was lowest in low-risk patients treated with anticoagulants alone, 6,765 of 331,430 (2.0%). Mortality was somewhat higher with catheter-directed thrombolysis, 195 of 6915 (2.8%; p <0.0001), and highest with intravenous thrombolysis 510 of 5,200 (9.8%; p <0.0001). Matched patients showed similar results. IVC filters did not reduce mortality in patients treated with anticoagulants alone. Mortality was only 0.5% higher in patients treated with anticoagulants who had saddle PE than in patients with nonsaddle PE, 450 of 17,935 (2.5%) versus 6,315 of 313,495 (2.0%; p <0.0001). However, a larger proportion of low-risk patients with saddle PE received catheter-directed thrombolysis than patients who had nonsaddle PE, 2,330 of 21,760 (11%) versus 4,585 of 321,785 (1.4%; p <0.0001). Similarly, a larger proportion of patients with saddle PE received intravenous thrombolytic therapy than patients with nonsaddle PE, 1,495 of 21,760 (6.9%) versus 3,705 of 321,785 (1.2%; p <0.0001). In conclusion, low-risk patients with PE did not have lower mortality with catheter-directed thrombolysis or intravenous thrombolytic therapy than with anticoagulants alone, and IVC filters did not reduce mortality with anticoagulants alone.
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http://dx.doi.org/10.1016/j.amjcard.2020.09.031DOI Listing
January 2021

Catheter-Directed Thrombolysis in Submassive Pulmonary Embolism and Acute Cor Pulmonale.

Am J Cardiol 2020 09 30;131:109-114. Epub 2020 Jun 30.

Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan.

Treatment of submassive (intermediate-risk) pulmonary embolism (PE), defined as hemodynamically stable with right ventricular (RV) dysfunction, showed lower in-hospital all-cause mortality with intravenous thrombolytic therapy than with anticoagulants, but at an increased risk of major bleeding. The present investigation was performed to test whether catheter-directed thrombolysis reduces mortality without increasing bleeding in submassive PE. This was a retrospective cohort study based on administrative data from the Nationwide Inpatient Sample. In 2016, 13,130 patients were hospitalized with PE and acute cor pulmonale, were stable, and treated with catheter-directed thrombolysis in 1,500 (11%) or anticoagulants alone in 11,630 (89%). Mortality was lower with catheter-directed thrombolysis than with anticoagulants in unmatched patients, 35 of 1,500 (2.3%) compared with 755 of 11,630 (6.5%; p <0.0001) and in matched patients, 30 of 1,260 (2.4%) compared with 440 of 6,910 (6.4%; p <0.0001). Time-dependent analysis showed catheter-directed thrombolysis reduced mortality if administered within the first 3 days. Patients with saddle PE treated with anticoagulants had lower mortality than non-saddle PE, 75 of 1,730 (4.3%) compared with 680 of 9,900 (6.9%; p < 0.0001) in unmatched patients and 45 of 1,305 (3.4%) compared with 395 of 5,605 (7.0%; p < 0.0001) in matched patients. Mortality was not lower with inferior vena cava filters either in those who received catheter-directed thrombolysis or those treated with anticoagulants. There were no fatal or nonfatal adverse events associated with catheter-directed thrombolysis. In conclusion, patients with submassive PE appear to have lower in-hospital all-cause mortality with catheter-directed thrombolysis administered within 3 days than with anticoagulants, and risks are low.
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http://dx.doi.org/10.1016/j.amjcard.2020.06.048DOI Listing
September 2020

Adjunctive Therapy and Mortality in Patients With Unstable Pulmonary Embolism.

Am J Cardiol 2020 06 4;125(12):1913-1919. Epub 2020 Apr 4.

Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan.

Mortality with adjunctive therapy in patients with unstable pulmonary embolism, defined as those in shock or on ventilator support, is sparsely studied and requires further investigation. This was a retrospective cohort study based on administrative data from the Nationwide Inpatient Sample, 2016. In-hospital all-cause mortality in unstable patients with acute pulmonary embolism was assessed according to treatment. Patients were identified by International Classification of Diseases-10-Clinical Modification Codes. Most unstable patients, 85%, received only anticoagulants. Their mortality was 3,080 of 6,635 (46%) without an inferior vena cava (IVC) filter, and mortality was much less with an IVC filter, 285 of 1,185 (24%) (p <0.0001). Mortality with catheter-directed thrombolysis alone, 70 of 235 (30%), did not differ significantly from mortality with anticoagulants plus an IVC filter, p = 0.07, although a trend favored the latter. Intravenous thrombolytic therapy without an IVC filter showed a mortality of 295 of 695 (42%) which tended to be lower than mortality with anticoagulants alone (p = 0.06). The addition of an IVC filter to intravenous thrombolytic therapy resulted in a mortality of 20 of 165 (12%), which was the lowest mortality with any combination of adjunctive treatments. Intravenous thrombolytic therapy, however, was associated with more adverse effects of therapy than catheter-directed thrombolysis or anticoagulants.
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http://dx.doi.org/10.1016/j.amjcard.2020.03.014DOI Listing
June 2020

Effect on Mortality With Inferior Vena Cava Filters in Patients Undergoing Pulmonary Embolectomy.

Am J Cardiol 2020 04 30;125(8):1276-1279. Epub 2020 Jan 30.

Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan.

In the absence of a randomized controlled trial, it is important to obtain as much evidence as possible by other methods on whether inferior vena cava (IVC) filters reduce mortality in patients who undergo pulmonary embolectomy. Therefore, this retrospective cohort study based data from the National Inpatient Sample 2009 to 2014 was undertaken. We assessed in-hospital all-cause mortality in stable and unstable (in shock or on ventilator support) patients with acute pulmonary embolism who underwent pulmonary embolectomy. International Classification of Diseases-9-Clinical Modification (ICD-9-CM) codes were used to identify patients. Co-morbidities were assessed by the updated Charlson co-morbidity index. A time-dependent analysis was performed to control for immortal time bias. In stable patients who underwent pulmonary embolectomy, mortality with an IVC filter was 50 of 1,212 (4.1%) compared with 202 of 755 (27%) with no IVC filter (p <0.0001). In unstable patients, mortality with an IVC filter was 108 of 598 (18%) compared with 179 of 358 (50%) with no IVC filter (p <0.0001). Mortality was reduced with IVC filters only if the filters were inserted in the first 4 or 5 days. Co-morbid conditions and immortal time bias could not explain these results. We conclude that both stable and unstable patients who underwent pulmonary embolectomy had a lower mortality with IVC filters if inserted in the first 4 or 5 days.
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http://dx.doi.org/10.1016/j.amjcard.2020.01.014DOI Listing
April 2020

Continuing Use of Inferior Vena Cava Filters Despite Data and Recommendations Against Their Use in Patients With Deep Venous Thrombosis.

Am J Cardiol 2019 11 22;124(10):1643-1645. Epub 2019 Aug 22.

Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan.

The purpose of the present investigation is to determine the response to the evidence and recommendations against the use of inferior vena cava (IVC) filters in patients with deep venous thrombosis (DVT). This was a retrospective cohort study based on administrative data from the National Hospital Discharge Survey 1979 to 2006 and from the National (Nationwide) Inpatient Sample 2007 to 2014. The number of IVC filters inserted in patients with lone DVT peaked in 2009 and then decreased from 2009 to 2014. The proportion of patients with lone DVT who received an IVC filter peaked in 2010 and then decreased from 2010 to 2014. Both the number of IVC filters inserted yearly and the proportion of patients who received an IVC filter remained higher than in 1998 when a randomized controlled trial showed no reduced mortality with permanent IVC filters in patients with DVT. In conclusion, large numbers of patients with lone DVT continue to receive IVC filters despite a randomized controlled trial that showed no reduced mortality with IVC filters in patients with DVT and despite clinical guideline recommendations against the use of IVC filters in such patients.
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http://dx.doi.org/10.1016/j.amjcard.2019.07.063DOI Listing
November 2019

Effectiveness of Inferior Vena Cava Filters in Patients With Stable and Unstable Pulmonary Embolism and Trends in Their Use.

Am J Med 2020 03 11;133(3):323-330. Epub 2019 Sep 11.

Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing.

Background: Trends in the use of inferior vena cava (IVC) filters in patients with pulmonary embolism (PE) who are stratified according to whether they are stable or unstable (in shock or ventilator dependent) may show where improvements of management could be made according to the best evidence that we now have.

Methods: This was a retrospective cohort study based on administrative data, 1999-2014, from the National (Nationwide) Inpatient Sample.

Results: In-hospital all-cause mortality in unstable patients who received an IVC filter was lower in each year of investigation and in all age groups. Mortality from 1999 to 2014 was 10,140 of 35,230 (28.8%) with an IVC filter compared with 54,018 of 116,642 (46.3%) without a filter (P <0.0001). In stable patients from 1999 to 2014, mortality with an IVC filter was 31,909 of 546,858 (5.8%) with an IVC filter compared with 220,443 of 3,367,783 (6.5%) without a filter (P <0.0001). In patients ages > 80 years, mortality in stable patients with an IVC filter was 7,438 of 114,457 (6.5%) with an IVC filter compared with 64,113 of 567,348 (11.3%) without an IVC filter (P <0.0001). The number of stable patients who received an IVC filter decreased from 2010 to 2014, but even in those years the largest number of IVC filters was inserted in stable patients, 194,502 of 212,611 (91.5%).

Conclusions: Mortality is markedly reduced in unstable patients who receive an IVC filter. Despite this, the proportion of unstable patients who receive an IVC filter is decreasing. The largest number of IVC filters continues to be inserted in stable patients, although there is no evidence of a clinically meaningful reduced mortality with IVC filters in stable patients unless age >80 years.
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http://dx.doi.org/10.1016/j.amjmed.2019.08.031DOI Listing
March 2020

Extended Thromboprophylaxis for Medical Patients.

Am J Med 2020 01 24;133(1):9-11. Epub 2019 Jun 24.

College of Medicine, University of Arizona, Tucson.

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http://dx.doi.org/10.1016/j.amjmed.2019.05.050DOI Listing
January 2020

Inferior Vena Cava Filters in Stable Patients With Pulmonary Embolism and Heart Failure.

Am J Cardiol 2019 07 23;124(2):292-295. Epub 2019 Apr 23.

Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan.

Mortality according to the use inferior vena cava (IVC) filters in patients with pulmonary embolism (PE) and heart failure (HF) has been sparsely studied. In the present investigation, we assess whether IVC filters in stable patients with PE and HF reduce mortality. This is a retrospective cohort study of administrative data from the Premier Healthcare Database, 2009 through 2015. Patients aged ≥18 years hospitalized with a primary diagnosis of PE and a discharge diagnosis of HF were identified by International Classification of Diseases-Ninth Revision-Clinical Modification codes. Exclusions were unstable patients (in shock or on a ventilator), patients who underwent pulmonary embolectomy, and patients with co-morbidities. In-hospital all-cause mortality was 102 of 2,423 (4.2%) with an IVC filter compared with 686 of 14,063 (4.9%) without an IVC filter (p = 0.16). Only patients aged >80 years showed a lower in-hospital all-cause mortality with IVC filters, 38 of 933 (4.1%) with an IVC filter compared with 307 of 4,486 (6.8%) without an IVC filter (p = 0.0012). In conclusion, stable patients with PE and HF, if aged >80 years, showed a reduced in-hospital all-cause mortality with IVC filters.
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http://dx.doi.org/10.1016/j.amjcard.2019.04.024DOI Listing
July 2019

Revisiting Results on Use of Inferior Vena Cava Filters in Older Adults.

JAMA Intern Med 2019 05;179(5):726-727

Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan.

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http://dx.doi.org/10.1001/jamainternmed.2019.0468DOI Listing
May 2019

Usefulness of Inferior Vena Cava Filters in Stable Patients with Acute Pulmonary Embolism.

Am J Cardiol 2019 06 14;123(11):1874-1877. Epub 2019 Mar 14.

Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan.

Retrospective cohort studies using administrative data from national databases or a registry suggest that there are subcategories of stable patients with acute pulmonary embolism who would show a reduced mortality with an inferior vena cava (IVC) filter in addition to anticoagulants. These subcategories are those who underwent pulmonary embolectomy, receiving thrombolytic therapy, suffering recurrent pulmonary embolism while on treatment, hospitalized with solid malignant tumors if aged >60 years, hospitalized with chronic obstructive pulmonary disease (COPD) if aged >50 years, and very elderly (aged >80 years). The following is a review of these studies. It is important to be circumspect in inferring a lower mortality with IVC filters based on comparative effectiveness research that uses national observational data. On the other hand, the likelihood of a randomized controlled trial in any of these subcategories of stable patients is remote. Whether patients are better served by inserting an IVC filter on the basis of retrospective cohort studies, or by withholding IVC filters until a randomized controlled trial can be obtained is a matter for consideration.
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http://dx.doi.org/10.1016/j.amjcard.2019.02.054DOI Listing
June 2019

Implications of Faint Heart Sounds After Acute Myocardial Infarction.

Authors:
Paul D Stein

Am J Cardiol 2019 05 13;123(9):1555-1556. Epub 2019 Feb 13.

College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan. Electronic address:

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http://dx.doi.org/10.1016/j.amjcard.2019.01.045DOI Listing
May 2019

The Reply.

Am J Med 2019 04 16;132(4):e552-e553. Epub 2019 Jan 16.

Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing.

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http://dx.doi.org/10.1016/j.amjmed.2018.12.013DOI Listing
April 2019

Mounting Evidence for Safe Home Treatment of Selected Patients With Acute Pulmonary Embolism.

Ann Intern Med 2018 12 13;169(12):881-882. Epub 2018 Nov 13.

Michigan State University College of Osteopathic Medicine, East Lansing, Michigan (P.D.S., M.J.H.).

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http://dx.doi.org/10.7326/M18-2869DOI Listing
December 2018

Inferior Vena Cava Filters in Patients with Recurrent Pulmonary Embolism.

Am J Med 2019 01 2;132(1):88-92. Epub 2018 Oct 2.

Department of Osteopathic Medical Specialties, College of Osteopathic Medicine.

Background: There are sparse data to support the recommendation for inferior vena cava (IVC) filters in patients with recurrent pulmonary embolism while on anticoagulant therapy.

Methods: This was a retrospective cohort study of administrative data from the Premier Healthcare Database, 2009-2014. All-cause mortality according to the use of IVC filters was evaluated in patients who suffered a recurrent pulmonary embolism within 3 months of an index pulmonary embolism. Patients were identified by International Classification of Disease, 9th Clinical Modification codes. A time-dependent analysis controlled for immortal time bias.

Results: An IVC filter was inserted in 603 of 814 (74.1%) of patients hospitalized for recurrent pulmonary embolism within 3 months of an index pulmonary embolism. Mortality with an IVC filter was 18 of 603 (3.0%) vs 83 of 211 (39.3%) (P < .0001) without a filter. Among patients with recurrent pulmonary embolism who were stable and did not receive thrombolytic therapy or undergo pulmonary embolectomy, mortality with an IVC filter was 15 of 572 (2.6%) vs 72 of 169 (42.6%) (P < .0001) without a filter.

Conclusion: In the United States, usual practice was to insert an IVC filter in patients with early recurrent pulmonary embolism. Mortality was lower in those who received an IVC filter. Even stable patients with early recurrent pulmonary embolism showed a decreased mortality with IVC filters, even though in other circumstances, IVC filters do not reduce mortality in stable patients. Additional cohort studies would be useful in the absence of a randomized controlled trial.
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http://dx.doi.org/10.1016/j.amjmed.2018.09.023DOI Listing
January 2019

Optimal Therapy for Unstable Pulmonary Embolism.

Am J Med 2019 02 2;132(2):168-171. Epub 2018 Oct 2.

Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing.

There are no randomized controlled trials of thrombolytic therapy, pulmonary embolectomy, or inferior vena cava (IVC) filters in patients with unstable pulmonary embolism (those in shock or on ventilator support). Yet, there are many investigations of these treatments based on retrospective cohort studies using administrative data from large government and commercial databases. Extensive data from these cohort studies showed that thrombolytic therapy resulted in the lowest in-hospital all-cause mortality. The results of thrombolytic therapy were greatly improved if IVC filters were added. In fact, IVC filters decreased in-hospital all-cause mortality with anticoagulants alone or with pulmonary embolectomy as well as thrombolytic therapy in adults of all ages with unstable pulmonary embolism. The IVC filters reduced mortality only if inserted on the day of admission or the next day, while the patients were unstable and in a fragile condition. We conclude that the best treatment for patients with unstable pulmonary embolism is thrombolytic therapy combined with an IVC filter inserted during the period of fragility, while the patient is unstable, and this treatment is indicated in all unstable patients irrespective of age.
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http://dx.doi.org/10.1016/j.amjmed.2018.09.018DOI Listing
February 2019

Pulmonary vein thrombosis in patients with medical risk factors.

Radiol Case Rep 2018 Dec 13;13(6):1170-1173. Epub 2018 Sep 13.

Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan.

Pulmonary vein thrombosis in patients with medical illnesses has been rarely reported, and it is also rarely reported in those with no risk factors. We report 2 patients with pulmonary vein thrombosis, 1 with metastatic renal cell carcinoma and 1 with presumed pulmonary aspergillosis. Thrombi or tumors in a pulmonary vein are clinically important because they may cause systemic embolism or hemoptysis.
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http://dx.doi.org/10.1016/j.radcr.2018.07.031DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6140413PMC
December 2018

The Reply.

Am J Med 2018 07;131(7):e313

Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing.

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http://dx.doi.org/10.1016/j.amjmed.2018.02.010DOI Listing
July 2018

Importance of Early Insertion of Inferior Vena Cava Filters in Unstable Patients with Acute Pulmonary Embolism.

Am J Med 2018 09 12;131(9):1104-1109. Epub 2018 Jun 12.

Department of Osteopathic Medical Specialties.

Background: Immortal time bias is a possible confounding factor in cohort studies. In this investigation, we assessed mortality with inferior vena cava (IVC) filters in unstable patients with pulmonary embolism using a design to control for immortal time bias.

Methods: Data were from the Premier Healthcare Database, 2010-2014. International Classification of Diseases-Ninth Revision-Clinical Modification codes were used. Unstable patients with pulmonary embolism and an admitting diagnosis of pulmonary embolism, as well as a primary diagnosis of pulmonary embolism, were included. A time-dependent analysis was used according to the day of insertion of the IVC filter to control for immortal time bias.

Results: Among all unstable patients, irrespective of the use of thrombolytic therapy, in-hospital all-cause mortality was 35 of 180 (19.4%) in those who received an IVC filter vs 122 of 299 (40.8%) with no filter (P < .0001). Mortality was lower in patients in whom the IVC filter was inserted on days 1 or 2 (on day 1, 21.4% compared with 40.8%, P = .017, and on day 2, 14.8% compared with 29.2%, P = .023), but it was not lower in those in whom the filter was inserted on subsequent days.

Conclusions: Mortality in unstable patients with pulmonary embolism appeared to be reduced with IVC filters only when the filter was inserted on the first or second day of admission. The design used for these analyses controlled for immortal time bias as a cause of the lower mortality with IVC filters.
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http://dx.doi.org/10.1016/j.amjmed.2018.05.023DOI Listing
September 2018

Prophylactic inferior vena cava filters in patients with fractures of the pelvis or long bones.

J Clin Orthop Trauma 2018 Apr-Jun;9(2):175-180. Epub 2017 Sep 29.

Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, United States.

Background: Which patients with fractures, if any, have a lower mortality with prophylactic inferior vena cava filters has yet to be established. The purpose of this investigation is to determine if patients with low-risk fractures might benefit from a prophylactic inferior vena cava filter.

Methods: Administrative data was analyzed from the National (Nationwide) Inpatient Sample using ICD-9-CM codes. Included patients were aged 18 years or older with a primary diagnosis of non-complex fracture of the pelvis, or fracture of the femuralone, or fracture of the tibia and/or fibula.

Results: From 2003-2012, 1,479,039 patients were hospitalized with low-risk fracture. The vast majority of patients with fracture, 1,461,378 of 1,479,039 (98.8%) did not receive an inferior vena cava filter. Among those who did not receive a filter, 1,446,489 of 1,461,378 (99.0%) did not develop deep venous thrombosis or pulmonary embolism. Pulmonary embolism without a filter occurred in 7207 of 1,461,378 (0.5%) and deep venous thrombosis occurred in 7682 of 1,461,378 (0.5%). Total in-hospital all-cause mortality in those who did not receive a filter was 15,683 of 1,461,378 (1.1%). An inferior vena cava filter was inserted in 17,661 of 1,479,039 (1.2%) of patients with fractures. Most of those who received an inferior vena cava filter, 12,025 of 17,661 (68.1%) did not develop pulmonary embolism or deep venous thrombosis. Total in-hospital all-cause mortality in all patients with an inferior vena cava filter was 516 of 17,661 (2.9%).

Conclusion: The evidence is the use of a prophylactic inferior cava vena filter in patients with a non-complex pelvic fracture or single fracture of the femur or fracture of the tibia and/or fibula.
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http://dx.doi.org/10.1016/j.jcot.2017.09.018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5995070PMC
September 2017

Usefulness of Inferior Vena Cava Filters in Unstable Patients With Acute Pulmonary Embolism and Patients Who Underwent Pulmonary Embolectomy.

Am J Cardiol 2018 02 23;121(4):495-500. Epub 2017 Nov 23.

Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan.

Administrative data were analyzed from the Premier Healthcare Database, 2010 to 2014, to assess whether inferior vena cava (IVC) filters reduce mortality in unstable patients (in shock or on ventilator support) with acute pulmonary embolism and in stable patients who undergo surgical pulmonary embolectomy. Mortality was assumed to be due to pulmonary embolism in patients who had none of the co-morbid conditions listed in the Charlson Comorbidity Index. Data were determined on the basis of International Classification of Disease-9th Clinical Modification (ICD-9-CM) codes. All-cause mortality in unstable patients was lower with IVC filters in-hospital, 288 of 1,972 (23%) versus 1339 of 3002 (45%) (p <0.0001), and at 3 months, all-cause mortality was 316 of 1,272 (25%) versus 1,428 of 3,002 (48%) (p <0.0001). Pulmonary embolism mortality was lower with IVC filters in unstable patients in-hospital, 191 of 926 (21%) versus 913 of 2,138 (43%) (p <0.0001) and at 3 months, 215 of 926 (23%) versus 971 of 2,138 (45%) (p <0.0001). A lower in-hospital and 3-month all-cause mortality and pulmonary embolism mortality was also shown with IVC filters in stable patients who underwent pulmonary embolectomy. These data, in concert with previous retrospective data, suggest that unstable patients with pulmonary embolism and stable patients who undergo pulmonary embolectomy may benefit from an IVC filter. Further investigations would be useful.
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http://dx.doi.org/10.1016/j.amjcard.2017.11.007DOI Listing
February 2018

Inferior Vena Cava Filters in Patients with Acute Pulmonary Embolism and Cancer.

Am J Med 2018 04 10;131(4):442.e9-442.e12. Epub 2017 Nov 10.

Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing.

Background: Administrative data have shown a lower mortality in hospitalized patients with pulmonary embolism and cancer who receive a vena cava filter. In the absence of a randomized controlled trial of vena cava filters in such patients, further investigation is necessary. Therefore, we performed this investigation using administrative data from a different database than used previously, and we investigate patients hospitalized in more recent years.

Methods: We analyzed administrative data from the Premier Healthcare Database, 2010-2014, in patients hospitalized with pulmonary embolism and solid malignant tumors. Patients were identified on the basis of International Classification of Disease, Ninth Revision, Clinical Modification codes.

Results: Patients aged >60 years had a lower in-hospital all-cause mortality with vena cava filters than those who did not have filters, 346 of 4648 (7.4%) compared with 2216 of 19,847 (11.2%) (P < .0001) (relative risk 0.67). Among patients aged >60 years who received an inferior vena cava, all-cause mortality within 3 months was 704 of 4648 (15.1%), compared with 3444 of 19,847 (17.4%) among those who did not receive a filter (P < .0001) (relative risk 0.86).

Conclusion: Elderly patients with pulmonary embolism and cancer may be a special population in whom inferior vena cava filters reduce in-hospital and 3-month all-cause mortality. Further investigation is needed, particularly in younger patients.
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http://dx.doi.org/10.1016/j.amjmed.2017.10.039DOI Listing
April 2018

Inferior Vena Cava Filters in Stable Patients with Acute Pulmonary Embolism Who Receive Thrombolytic Therapy.

Am J Med 2018 Jan 12;131(1):97-99. Epub 2017 Aug 12.

Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, Mich.

Background: There is a need for further analyses of subgroups of patients with pulmonary embolism who might benefit from vena cava filters. In the present investigation, we analyze mortality with vena cava filters in the subgroup of stable patients with pulmonary embolism who received thrombolytic therapy. We use a different database than used previously, and we analyze data in more recent years.

Methods: Administrative data were analyzed from the Premier Healthcare Database, 2010-2014, in hospitalized stable patients with pulmonary embolism who received thrombolytic therapy and may or may not have received a vena cava filter. Patients were identified on the basis of International Classification of Disease, Ninth Revision, Clinical Modification codes.

Results: In-hospital all-cause mortality in stable patients who received a vena cava filter in addition to thrombolytic therapy was 139 of 2660 (5.2%), compared with 697 of 4332 (16.1%) who did not receive a filter (P < .0001) (relative risk .32). Mortality was lower with a filter every decade of age ≥ 31 years.

Conclusion: Among stable patients with acute pulmonary embolism who receive thrombolytic therapy, irrespective of the reason, the additional use of an inferior vena cava filter results in a lower in-hospital mortality.
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http://dx.doi.org/10.1016/j.amjmed.2017.07.028DOI Listing
January 2018

CT Pulmonary Angiography in Young Women.

Clin Appl Thromb Hemost 2018 Apr 8;24(3):423-428. Epub 2017 May 8.

1 Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA.

The purpose was to determine whether young women in the emergency department who received computed tomographic (CT) pulmonary angiograms were evaluated to receive lower dose imaging or no imaging, recognizing that the risks of radiation are particularly high in young women. This was a retrospective cohort investigation of women aged 18 to 29 years seen for suspected acute pulmonary embolism in emergency departments of 5 regional hospitals from May 1, 2015 to April 30, 2016. Computed tomographic (CT) pulmonary angiograms were obtained in 379 young women. Pulmonary embolism was diagnosed by CT angiography in 2.1%. A Wells probability score could be calculated in 11.9%. D-dimer was obtained in 46.2% and a chest radiograph was obtained in 41.7%. Among patients with a normal chest radiograph, 3.9% had a lung scan. Venous ultrasound of the lower extremities was obtained in 1.8%. Each had an elevated D-dimer. Among the young women who received CT angiograms, 53 were pregnant. In 17.0% of pregnant women, a Wells clinical probability score could be calculated from the medical record. D-dimer in pregnant women was obtained in 30.2%, chest radiograph in 22.6%, lung scan in 11.3%, and venous ultrasound of the lower extremities in none. In conclusion, young women and pregnant women often received CT pulmonary angiograms for suspected acute pulmonary embolism without an objective clinical assessment, measurement of D-dimer, lung scintiscan, or venous ultrasound, which may have eliminated the need for CT pulmonary angiography in many instances.
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http://dx.doi.org/10.1177/1076029617707038DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6714652PMC
April 2018

Diagnostic accuracy of magnetic resonance imaging in patients with suspected pulmonary embolism: A bivariate meta-analysis.

Thromb Res 2017 Jun 7;154:64-72. Epub 2017 Apr 7.

Research Center on Thromboembolic Disorders and Antithrombotic Therapies, Department of Medicine and Surgery, University of Insubria, Varese, Italy.

Background: Computed tomographic pulmonary angiography (CTPA) has simplified the diagnostic approach to patients with clinically suspected pulmonary embolism (PE), but alternative imaging tests are still advocated. We aimed to systematically assess the diagnostic accuracy of magnetic resonance imaging (MRI) for PE diagnosis.

Methods: Studies evaluating the diagnostic accuracy of MRI for the diagnosis of PE were systematically searched in the PubMed and EMBASE databases (up to May 2016). QUADAS - 2 tool was used for the quality assessment of the primary studies. A bivariate random-effects regression approach was used for summary estimates of both sensitivity and specificity.

Results: Thirteen studies, for a total of 1170 patients, were included. Weighted mean prevalence of PE was 37% at random-effect model. Weighted mean inconclusive MRI results were 19% at random-effect model. After exclusion of technical inadequate results, MRI bivariate weighted mean sensitivity was 80.9% (95% confidence interval [CI] 68.2, 89.4%), with a bivariate weighted mean specificity of 96.4% (95% CI 92.4, 98.3%), CONCLUSIONS: MRI has high specificity but limited sensitivity for the diagnosis of PE. Inconclusive results are a major limitation to the practical application of MRI. Management studies are needed to more precisely define the role of MRI in the diagnostic workup of patients with suspected PE.
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http://dx.doi.org/10.1016/j.thromres.2017.03.027DOI Listing
June 2017

Inferior Vena Cava Filters in Elderly Patients with Stable Acute Pulmonary Embolism.

Am J Med 2017 Mar 29;130(3):356-364. Epub 2016 Oct 29.

Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing.

Background: Patients aged >60 years with pulmonary embolism who were stable and did not require thrombolytic therapy were shown to have a somewhat lower in-hospital all-cause mortality with vena cava filters. In this investigation we further assess mortality with filters in stable elderly patients.

Methods: In-hospital all-cause mortality according to use of inferior vena cava filters was assessed from the National (Nationwide) Inpatient Sample, 2003-2012, in: 1) All patients with pulmonary embolism; 2) All with pulmonary embolism who had none of the comorbid conditions listed in the Charlson Comorbidity Index; 3) Patients with a primary (first-listed) diagnosis of pulmonary embolism, and 4) Patients with a primary diagnosis of pulmonary embolism and none of the comorbid conditions listed in the Charlson Comorbidity Index.

Results: From 2003-2012, 2,621,575 stable patients with pulmonary embolism were hospitalized in the US. Patients aged >80 years showed lower mortality with vena cava filters (all pulmonary embolism, 6.1% vs 10.5%; all pulmonary embolism with no comorbid conditions, 3.3% vs 6.3%; primary pulmonary embolism, 4.1% vs 5.7%; primary pulmonary embolism with no comorbid conditions, 2.1% vs 3.7%; all P <.0001). In the all-patient category, patients aged 71-80 years showed somewhat lower mortality with filters, 6.3% vs 7.4% (P <.0001), and those without comorbid conditions, 2.5% vs 2.8% (P = .04). Those aged 71-80 years with primary pulmonary embolism, irrespective of comorbid conditions, did not show lower mortality with filters.

Conclusion: At present, in the absence of a randomized controlled trial, it seems prudent to consider a vena cava filter in very elderly (aged >80 years) stable patients with acute pulmonary embolism.
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http://dx.doi.org/10.1016/j.amjmed.2016.09.033DOI Listing
March 2017