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Denis Doyen, MD; Emile Ferrari, MD
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From the Department of Cardiology, Pasteur University Hospital, Nice, France.

CORRESPONDENCE TO: Denis Doyen, MD, Department of Cardiology, Pasteur University Hospital, 30 Av de la Voie Romaine, 06002, Nice, France; e-mail: doyen.d@chu-nice.fr


FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;146(5):e169-e170. doi:10.1378/chest.14-1529
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To the Editor:

We read with great interest the correspondence from Drs Bradford and Farber concerning our recent article in CHEST.1 They questioned the validity of the intermediate-risk pulmonary embolism (PE) definition based on European Society of Cardiology (ESC) criteria.2 Indeed, the mortality observed in our study (2.4%), as in the recent Pulmonary Embolism Thrombolysis (PEITHO)3 trial, was lower than expected (3%-15%),2 suggesting that current intermediate-risk PE risk stratification is not accurate.

We agree that ESC risk stratification concerning intermediate-risk PE may be heterogeneous, because patients may have very different risks of mortality. Recently, Bova et al4 subdivided patients with intermediate-risk PE into three different groups of mortality. They computed a risk score using right ventricular dysfunction, elevated troponin level, heart rate ≥ 110 beats/min, and systolic BP between 90 and 100 mm Hg. Mortality was 1.7%, 5.0%, and 15.5% for stages I, II, and III, respectively. Inclusion of systolic BP and heart rate allowed more accurate risk stratification.

However, using this score, our population still remains at a high risk of mortality. Indeed, stages II and III concerned 48.8% and 24.4% of patients, respectively. The expected mortality should have been between approximately 5% and 15.5%. To explain the lower mortality observed (2.4%), we offer these hypotheses. In our city (about 532,000 people), a network has been built to recruit all cases of PE. This has allowed us to manage about 120 to 150 cases of PE every year. We believe that, as with many other diseases, the greater the number of cases treated, the better the prognosis; furthermore, all of these patients were hospitalized in the cardiac ICU for at least 1 or 2 days, with continuous monitoring and regular adaptation of treatment. We also suggest that PE management has improved worldwide after 2008 ESC guidelines publication. Analysis of the main studies involving intermediate-risk PE from 2009 to 2014 suggested that the global intermediate-risk PE mortality decreased by between 2% and 10%.4

We, therefore, believe that these patients are representative of an intermediate-risk PE population, and our findings should be considered for intermediate-risk PE management: A large patent foramen ovale (PFO) correlated with a 43.8% risk of stroke. The presence of a PFO should explain the risk of hemorrhagic transformation with fibrinolysis. Intracranial bleeding is the main event that explains the lack of superiority in the fibrinolytic group of the PEITHO trial. We believe that PFO screening could help select the population that benefits most from fibrinolysis.

References

Doyen D, Castellani M, Moceri P, et al. Patent foramen ovale and stroke in intermediate-risk pulmonary embolism. Chest. 2014;146(4):967-973. [CrossRef] [PubMed]
 
Torbicki A, Perrier A, Konstantinides S, et al; ESC Committee for Practice Guidelines (CPG). Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J. 2008;29(18):2276-2315. [CrossRef] [PubMed]
 
Meyer G, Vicaut E, Danays T, et al; PEITHO Investigators. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med. 2014;370(15):1402-1411. [CrossRef] [PubMed]
 
Bova C, Sanchez O, Prandoni P, et al. Identification of intermediate-risk patients with acute symptomatic pulmonary embolism. Eur Respir J. In press. doi: 10.1183/09031936.00006114.
 

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Tables

References

Doyen D, Castellani M, Moceri P, et al. Patent foramen ovale and stroke in intermediate-risk pulmonary embolism. Chest. 2014;146(4):967-973. [CrossRef] [PubMed]
 
Torbicki A, Perrier A, Konstantinides S, et al; ESC Committee for Practice Guidelines (CPG). Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J. 2008;29(18):2276-2315. [CrossRef] [PubMed]
 
Meyer G, Vicaut E, Danays T, et al; PEITHO Investigators. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med. 2014;370(15):1402-1411. [CrossRef] [PubMed]
 
Bova C, Sanchez O, Prandoni P, et al. Identification of intermediate-risk patients with acute symptomatic pulmonary embolism. Eur Respir J. In press. doi: 10.1183/09031936.00006114.
 
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