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Rodger MA, Le Gal G, Wells P, Baglin T, Aujesky D, Righini M, Palareti G, Huisman M, Meyer G. Clinical decision rules and D-Dimer in venous thromboembolism: current controversies and future research priorities. Thromb Res 2014; 134:763-8. [PMID: 25129416 DOI: 10.1016/j.thromres.2014.07.031] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Revised: 07/25/2014] [Accepted: 07/27/2014] [Indexed: 12/21/2022]
Abstract
Venous thromboembolism (VTE) is a potentially lethal clinical condition that is suspected in patients with common clinical complaints, in many and varied, clinical care settings. Once VTE is diagnosed, optimal therapeutic management (thrombolysis, IVC filters, type and duration of anticoagulants) and ideal therapeutic management settings (outpatient, critical care) are also controversial. Clinical prediction tools, including clinical decision rules and D-Dimer, have been developed, and some validated, to assist clinical decision making along the diagnostic and therapeutic management paths for VTE. Despite these developments, practice variation is high and there remain many controversies in the use of the clinical prediction tools. In this narrative review, we highlight challenges and controversies in VTE diagnostic and therapeutic management with a focus on clinical decision rules and D-Dimer.
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Affiliation(s)
- Marc A Rodger
- Hematology, University of Ottawa and The Ottawa Hospital, Ottawa, ON Canada; Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON Canada; Obstetrics and Gynaecology, University of Ottawa and The Ottawa Hospital, Ottawa, ON Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada.
| | - Gregoire Le Gal
- Hematology, University of Ottawa and The Ottawa Hospital, Ottawa, ON Canada; Obstetrics and Gynaecology, University of Ottawa and The Ottawa Hospital, Ottawa, ON Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Philip Wells
- Hematology, University of Ottawa and The Ottawa Hospital, Ottawa, ON Canada; Obstetrics and Gynaecology, University of Ottawa and The Ottawa Hospital, Ottawa, ON Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Trevor Baglin
- Cambridge Haemophilia and Thrombophilia Centre, Addenbrookes Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Drahomir Aujesky
- Division of General Internal Medicine, Bern University Hospital, Bern, Switzerland
| | - Marc Righini
- Division of Angiology and Hemostasis, Department of Medical Specialties, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland
| | - Gualtiero Palareti
- Unit of Angiology and Blood Coagulation, University Hospital of Bologna, Italy
| | - Menno Huisman
- Department of Thrombosis and Hemostasis, LUMC, Leiden, the Netherlands
| | - Guy Meyer
- Université Paris Descartes Sorbonne Paris Cité and Hopital europeen Georges Pompidou APHP, Paris, France
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102
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García-Sanz M, Pena-Álvarez C, López-Landeiro P, Bermo-Domínguez A, Fontúrbel T, González-Barcala F. Symptoms, location and prognosis of pulmonary embolism. REVISTA PORTUGUESA DE PNEUMOLOGIA 2014; 20:194-9. [DOI: 10.1016/j.rppneu.2013.09.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Revised: 09/05/2013] [Accepted: 09/21/2013] [Indexed: 10/25/2022] Open
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The use of axial diameters and CT obstruction scores for determining echocardiographic right ventricular dysfunction in patients with acute pulmonary embolism. Jpn J Radiol 2014; 32:451-60. [DOI: 10.1007/s11604-014-0327-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Accepted: 04/26/2014] [Indexed: 10/25/2022]
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104
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Sanjuán P, Rodríguez-Núñez N, Rábade C, Lama A, Ferreiro L, González-Barcala FJ, Álvarez-Dobaño JM, Toubes ME, Golpe A, Valdés L. Probability Scores and Diagnostic Algorithms in Pulmonary Embolism: Are They Followed in Clinical Practice? ACTA ACUST UNITED AC 2014. [DOI: 10.1016/j.arbr.2014.03.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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105
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Sanjuán P, Rodríguez-Núñez N, Rábade C, Lama A, Ferreiro L, González-Barcala FJ, Álvarez-Dobaño JM, Toubes ME, Golpe A, Valdés L. Escalas de probabilidad clínica y algoritmo diagnóstico en la embolia pulmonar: ¿se siguen en la práctica clínica? Arch Bronconeumol 2014; 50:172-8. [DOI: 10.1016/j.arbres.2013.11.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Revised: 11/06/2013] [Accepted: 11/08/2013] [Indexed: 11/26/2022]
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Robert-Ebadi H, Righini M. Diagnosis and management of pulmonary embolism in the elderly. Eur J Intern Med 2014; 25:343-9. [PMID: 24703814 DOI: 10.1016/j.ejim.2014.03.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Revised: 03/11/2014] [Accepted: 03/12/2014] [Indexed: 12/15/2022]
Abstract
Elderly patients are a population not only at particularly high risk of venous thromboembolism including pulmonary embolism (PE), but also at high risk of adverse clinical outcomes and treatment-related complications. Major progresses have been achieved in the diagnosis and treatment of PE over the last two decades. Nevertheless, some of elderly patients' specificities still represent important challenges in the management of PE in this population, from its suspicion to its diagnosis and treatment, and are discussed in this review. Perspectives for the future are from a diagnostic point of view the potential implementation of age-adjusted d-dimer cut-offs that will allow ruling out PE in a greater proportion of elderly patients without the need for thoracic imaging. From a therapeutic point of view, acquisition of post-marketing clinical experience with the use of new oral anticoagulants is still necessary, and in the meantime, these drugs should be prescribed with great caution in thoroughly selected elderly patients.
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Affiliation(s)
- Helia Robert-Ebadi
- Angiology and Haemostasis Unit, University Hospitals of Geneva, Switzerland.
| | - Marc Righini
- Angiology and Haemostasis Unit, University Hospitals of Geneva, Switzerland
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Duplyakov D, Kurakina E, Pavlova T, Khokhlunov S, Surkova E. Value of syncope in patients with high-to-intermediate risk pulmonary artery embolism. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2014; 4:353-8. [PMID: 24619817 DOI: 10.1177/2048872614527837] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2013] [Accepted: 02/22/2014] [Indexed: 01/13/2023]
Abstract
BACKGROUND Syncope may develop in 9-35% of patients with pulmonary embolism (PE). Despite its severity and importance, the prognostic value of syncope in PE is unclear. We aimed to assess the value of syncope in patients with high-to-intermediate risk PE. METHODS A total of 117 patients (62 males and 55 females, median age 51,86 ± 13,4 years) were enrolled into the study. According to the presence of syncope at the onset of PE, all patients were divided into two groups: the syncope group (SG) comprised 35 patients (48.8 ± 15.5 years, male 54.3%) who experienced at least one syncopal episode. The remaining 82 patients (53.4 ± 12.6 years, male 42.7%) without syncope comprised the control group (CG). RESULTS The main predisposing risk factors of PE were the same except fewer recurrent episodes of PE (8.5 vs. 24.5% in patients from SG (p=0.048). Clinical probability of PE according to the Revised Geneva and Wells scores was high almost in every second patient in both groups (p=NS). There were twice as many patients with a high risk of fatal outcome among patients with syncope in comparison with CG patients (45.7 vs. 25.6%, respectively, p=0.032). Massive PE on computed tomography scans was found again significantly more frequently in patients with syncope (60 vs. 39%, p=0.036). The vast majority (60%) of patients with a history of syncope were treated by thrombolytic therapy (21/35) vs. only 29% of patients without syncopal events (24/82; p=0.001). In-hospital mortality was higher in patients with syncope than the control group (14.2 vs. 8.5%, p=NS). CONCLUSIONS The history of syncope in patients with suspected PE should be considered as a possible criterion of high risk of fatal complications of in-hospital period due to frequent embolism of the pulmonary trunk and its main branches. The use of thrombolytic therapy showed a tendency in improving outcomes.
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Affiliation(s)
- Dmitry Duplyakov
- Samara Regional Cardiology Dispensary, Samara, Russia Samara State Medical University, Samara, Russia
| | | | - Tatyana Pavlova
- Samara Regional Cardiology Dispensary, Samara, Russia Samara State Medical University, Samara, Russia
| | - Sergey Khokhlunov
- Samara Regional Cardiology Dispensary, Samara, Russia Samara State Medical University, Samara, Russia
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Diagnostic et traitement de la maladie thromboembolique veineuse en 2013. ARCHIVES OF CARDIOVASCULAR DISEASES SUPPLEMENTS 2014. [DOI: 10.1016/s1878-6480(14)71482-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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109
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Managing pulmonary embolism from presentation to extended treatment. Thromb Res 2014; 133:139-48. [DOI: 10.1016/j.thromres.2013.09.040] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Revised: 09/26/2013] [Accepted: 09/29/2013] [Indexed: 11/19/2022]
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Polo Friz H, Pasciuti L, Meloni DF, Crippa M, Villa G, Molteni M, Primitz L, Del Sorbo D, Delgrossi G, Cimminiello C. A higher d-dimer threshold safely rules-out pulmonary embolism in very elderly emergency department patients. Thromb Res 2014; 133:380-3. [PMID: 24439678 DOI: 10.1016/j.thromres.2013.12.045] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Revised: 12/24/2013] [Accepted: 12/31/2013] [Indexed: 11/25/2022]
Abstract
INTRODUCTION D-dimer is commonly used in the workup of suspected Pulmonary Embolism (PE), but its specificity decreases with age. We evaluated whether using a higher cutoff value for D-dimer could increase the test specificity without reducing its sensitivity for ruling-out PE in elderly and very elderly patients presenting to the Emergency Department (ED). MATERIAL AND METHODS All patients with D-dimer and pulmonary Computed Tomography Angiography (CTA) performed in the ED of Vimercate Hospital, from 2010 through 2012 for clinical suspicion of PE were included in this retrospective cohort study. RESULTS Study population 481 patients (63.4% women, mean age 73.0 ± 16.1 years, confirmed PE 22.5%). In very elderly patients (aged 80 or more years, n=191), compared with standard 490 ng/mL D-dimer threshold, both higher fixed (1000 ng/mL) and age-adjusted cutoffs increase the specificity of D-dimer for the exclusion of PE maintaining a Negative Predictive Value of 100%. Potentially avoided CTAs were 12(6.3%) using 1000 ng/mL cutoff and 10(5.2%) age-adjusted. In very elderly patients the Number Needed to Test was incalculable for the standard cutoff (0 cases), 16 for 1000 ng/mL and 19 for age-adjusted. In patients with PE, index episode mortality was 6.5%, and death occurred only in subjects with D-dimer values above 1000ng/mL and age-adjusted thresholds. CONCLUSION For very elderly patients with suspected PE in ED, both higher fixed D-dimer (1000 ng/mL) and age-adjusted thresholds increase test specificity for excluding PE without reducing its sensitivity, leading to a safe reduction in the number of CTAs.
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Affiliation(s)
- Hernan Polo Friz
- Internal Medicine, Medical Department, Vimercate Hospital, Vimercate, Italy.
| | - Lorenzo Pasciuti
- Internal Medicine, Medical Department, Vimercate Hospital, Vimercate, Italy
| | | | - Matteo Crippa
- Internal Medicine, Medical Department, Vimercate Hospital, Vimercate, Italy
| | - Giulia Villa
- Internal Medicine, Medical Department, Vimercate Hospital, Vimercate, Italy
| | - Mauro Molteni
- Internal Medicine, Medical Department, Vimercate Hospital, Vimercate, Italy
| | - Laura Primitz
- Internal Medicine, Medical Department, Vimercate Hospital, Vimercate, Italy
| | - Davide Del Sorbo
- Internal Medicine, Medical Department, Vimercate Hospital, Vimercate, Italy
| | - Giovanni Delgrossi
- Internal Medicine, Medical Department, Vimercate Hospital, Vimercate, Italy
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111
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Lavorini F, Di Bello V, De Rimini ML, Lucignani G, Marconi L, Palareti G, Pesavento R, Prisco D, Santini M, Sverzellati N, Palla A, Pistolesi M. Diagnosis and treatment of pulmonary embolism: a multidisciplinary approach. Multidiscip Respir Med 2013; 8:75. [PMID: 24354912 PMCID: PMC3878229 DOI: 10.1186/2049-6958-8-75] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Accepted: 12/13/2013] [Indexed: 02/02/2023] Open
Abstract
The diagnosis of pulmonary embolism (PE) is frequently considered in patients presenting to the emergency department or when hospitalized. Although early treatment is highly effective, PE is underdiagnosed and, therefore, the disease remains a major health problem. Since symptoms and signs are non specific and the consequences of anticoagulant treatment are considerable, objective tests to either establish or refute the diagnosis have become a standard of care. Diagnostic strategy should be based on clinical evaluation of the probability of PE. The accuracy of diagnostic tests for PE are high when the results are concordant with the clinical assessment. Additional testing is necessary when the test results are inconsistent with clinical probability. The present review article represents the consensus-based recommendations of the Interdisciplinary Association for Research in Lung Disease (AIMAR) multidisciplinary Task Force for diagnosis and treatment of PE. The aim of this review is to provide clinicians a practical diagnostic and therapeutic management approach using evidence from the literature.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Massimo Pistolesi
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla 3, Florence 50134, Italy.
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112
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Risk Stratification of Patients with AECOPD. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2013. [DOI: 10.1007/s40138-013-0024-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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113
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Idiopathic thrombosis of the inferior vena cava and bilateral femoral veins in an otherwise healthy male soldier. Case Rep Med 2013; 2013:246201. [PMID: 24187556 PMCID: PMC3800672 DOI: 10.1155/2013/246201] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2013] [Revised: 08/14/2013] [Accepted: 09/03/2013] [Indexed: 12/31/2022] Open
Abstract
Thrombosis of the inferior vena cava is less common than deep venous thrombosis of the lower extremities, particularly in the absence of an obvious congenital caval abnormality or hypercoagulable state. We present a case of IVC thrombosis in an otherwise healthy and active 28-year-old male soldier secondary to dehydration and venous webbing. IVC thrombosis is an uncommon and underrecognized condition; in this case, the patient's caval thrombosis was initially mistaken for acute back strain. Prompt recognition is necessary to minimize long-term sequelae.
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114
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Abstract
ZusammenfassungDas Auftreten sowohl der tiefen Beinvenenthrombose als auch einer Lungenarterienembolie wird bereits durch physiologische Mechanismen in der Schwangerschaft und im Wochenbett begünstigt. Es kommt neben vorbestehenden Risikofaktoren zu transienten Erscheinungen, die das Risiko für venöse thromboembolische Erkrankungen erhöhen. Die Klinik von Thromboembolien ist oft unspezifisch. Erprobte Diagnosealgorithmen bestehen in der Schwangerschaft nicht. Aufgrund der klinischen Relevanz ist jedoch eine Diagnosesicherung unerlässlich. Die Anamnese, Klinik und Labordiagnostik sind wesentliche Bestandteile in der Diagnosefin-dung, können aber alleine eine venöse Thromboembolie nicht ausschließen. Eine apparative Beurteilung der betroffenen Venen durch die Sonographie ist dabei die Untersuchungsmethode der Wahl. Die vorliegende Arbeit beschreibt die Diagnostik und Therapie venöser Thromboembolien in der Schwangerschaft.
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115
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Soo Hoo GW. Overview and assessment of risk factors for pulmonary embolism. Expert Rev Respir Med 2013; 7:171-91. [PMID: 23547993 DOI: 10.1586/ers.13.7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Pulmonary embolism is one of the most common undiagnosed conditions affecting hospitalized patients. There are a plethora of risk factors for venous thromboembolism and pulmonary emboli. These factors are grouped under the broad triad of hypercoagulability, stasis and injury to provide a framework for understanding. Important risk factors include inherited thrombophilia, age, malignancy and estrogens. These risk factors are reviewed in detail and several risk assessment models are reviewed. These risk assessment models help identify those at risk for disease and therefore candidates for thromboprophylaxis. Diagnosis can be difficult and is aided by clinical decision rules that incorporate clinical scores that define the likelihood of pulmonary embolism. These are important considerations, not only for diagnostic purposes, but also to minimize excessive use of imaging, which increases exposure to and risks associated with radiation. A healthy index of suspicion is often the key to diagnosis.
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Affiliation(s)
- Guy W Soo Hoo
- Pulmonary and Critical Care Section, West Los Angeles Veterans Affairs Healthcare Center, Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
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116
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Utilization of CT Pulmonary Angiography in Suspected Pulmonary Embolism in a Major Urban Emergency Department. Pulm Med 2013; 2013:915213. [PMID: 24078873 PMCID: PMC3783975 DOI: 10.1155/2013/915213] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Accepted: 07/28/2013] [Indexed: 11/17/2022] Open
Abstract
Objectives. We conducted a study to answer 3 questions: (1) is CT pulmonary angiography (CTPA) overutilized in suspected pulmonary embolism (PE)? (2) What alternative diagnoses are provided by CTPA? (3) Can CTPA be used to evaluate right ventricular dilatation (RVD)? Methods. We retrospectively reviewed the clinical information of 231 consecutive emergency department patients who underwent CTPA for suspected PE over a one-year period. Results. The mean age of our patients was 53 years, and 58.4% were women. The prevalence of PE was 20.7%. Among the 136 patients with low clinical probability of PE, a d-dimer test was done in 54.4%, and it was normal in 24.3%; none of these patients had PE. The most common alternative findings on CTPA were emphysema (7.6%), pneumonia (7%), atelectasis (5.5%), bronchiectasis (3.8%), and congestive heart failure (3.3%). The sensitivity and negative predictive value of CTPA for (RVD) was 92% and 80%, respectively. Conclusions. PE could have been excluded without CTPA in ~1 out of 4 patients with low clinical probability of PE, if a formal assessment of probability and d-dimer test had been done. In patients without PE, CTPA did not provide an alternative diagnosis in 65%. In patients with PE, CTPA showed the potential to evaluate RVD.
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117
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Zwaan L, Thijs A, Wagner C, Timmermans DRM. Application of an evidence-based decision rule to patients with suspected pulmonary embolism. J Eval Clin Pract 2013; 19:682-8. [PMID: 23279113 DOI: 10.1111/jep.12019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/08/2012] [Indexed: 11/29/2022]
Abstract
RATIONALE To support doctors in diagnosing patients who are suspected to have pulmonary embolism, the Christopher evidence-based decision rule was implemented in hospitals in the Netherlands. This study examines whether the Christopher evidence-based decision rule is applied in clinical practice. In addition, doctors' considerations for not applying the decision rule are explored. METHOD Dyspnoea patients were included in the study prospectively. The diagnostic process of the patients with suspected pulmonary embolism, as judged by the treating doctor, was compared with the Christopher evidence-based decision rule using patient record reviews. In addition, 14 interviews were conducted with doctors who did not follow the Christopher evidence-based decision rule to obtain insights into their considerations. RESULTS In 80 of 247 dyspnoea cases, the treating doctors suspected pulmonary embolism. The Christopher evidence-based decision rule was applied in 17 out of 80 cases. In 22 cases, more tests were performed than was suggested by the decision rule [i.e. computer-assisted tomographic angiography (CTa) or D-dimer], while in 41 cases fewer tests were performed than suggested by the decision rule. Considerations for not following the decision rule included judging another diagnosis to be more likely and not wanting to expose the patient to CTa radiation. CONCLUSIONS The Christopher evidence-based decision rule for diagnosing pulmonary embolism was not always followed in everyday clinical practice. Doctors seem to base their diagnostic strategy on their own estimate of the likelihood of pulmonary embolism, rather than the whole decision rule. Better adherence to the decision rule could be beneficial by making doctors aware that pulmonary embolism is more likely than they initially thought. However, in a substantial number of cases, it seemed justifiable that doctors deviated from the decision rule. Therefore, further research is needed to determine the value of the Christopher evidence-based decision rule in clinical practice.
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Affiliation(s)
- Laura Zwaan
- Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands.
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118
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CT pulmonary angiography: increasingly diagnosing less severe pulmonary emboli. PLoS One 2013; 8:e65669. [PMID: 23776522 PMCID: PMC3680477 DOI: 10.1371/journal.pone.0065669] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Accepted: 04/27/2013] [Indexed: 01/26/2023] Open
Abstract
Background It is unknown whether the observed increase in computed tomography pulmonary angiography (CTPA) utilization has resulted in increased detection of pulmonary emboli (PEs) with a less severe disease spectrum. Methods Trends in utilization, diagnostic yield, and disease severity were evaluated for 4,048 consecutive initial CTPAs performed in adult patients in the emergency department of a large urban academic medical center between 1/1/2004 and 10/31/2009. Transthoracic echocardiography (TTE) findings and peak serum troponin levels were evaluated to assess for the presence of PE-associated right ventricular (RV) abnormalities (dysfunction or dilatation) and myocardial injury, respectively. Statistical analyses were performed using multivariate logistic regression. Results 268 CTPAs (6.6%) were positive for acute PE, and 3,780 (93.4%) demonstrated either no PE or chronic PE. There was a significant increase in the likelihood of undergoing CTPA per year during the study period (odds ratio [OR] 1.05, 95% confidence interval [CI] 1.04–1.07, P<0.01). There was no significant change in the likelihood of having a CTPA diagnostic of an acute PE per year (OR 1.03, 95% CI 0.95–1.11, P = 0.49). The likelihood of diagnosing a less severe PE on CTPA with no associated RV abnormalities or myocardial injury increased per year during the study period (OR 1.39, 95% CI 1.10–1.75, P = 0.01). Conclusions CTPA utilization has risen with no corresponding change in diagnostic yield, resulting in an increase in PE detection. There is a concurrent rise in the likelihood of diagnosing a less clinically severe spectrum of PEs.
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Affiliation(s)
- Massimo Miniati
- Dipartimento di Medicina, Sperimentale e Clinica, Università di Firenze, Firenze, Italy.
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120
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Zakai NA, Callas PW, Repp AB, Cushman M. Venous thrombosis risk assessment in medical inpatients: the medical inpatients and thrombosis (MITH) study. J Thromb Haemost 2013; 11:634-41. [PMID: 23336744 DOI: 10.1111/jth.12147] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Accepted: 01/15/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND We sought to define the risk factors present at admission for venous thromboembolism (VTE) in medical inpatients and develop a risk model for clinical use. METHODS Between January 2002 and June 2009, 299 cases of hospital-acquired VTE were frequency matched to 601 controls. Records were abstracted using a standard form for characteristics of the thrombosis, medical conditions and other risk factors. Weighted logistic regression and survey methods were used to develop a risk model for hospital-acquired VTE that was validated by bootstrapping. RESULTS VTE complicated 4.6 per 1000 admissions. Two risk assessment models were developed, one using laboratory data available at admission (Model 1) and the other excluding laboratory data (Model 2). Model 1 consisted of the following risk factors (points): history of congestive heart failure (5), history of inflammatory disease (4), fracture in the past 3 months (3), history of VTE (2), history of cancer in the past 12 months (1), tachycardia (2), respiratory dysfunction (1), white cell count ≥ 11 × 10(9) /L (1), and platelet count ≥ 350 × 10(9) /L (1). Model 2 was similar, except respiratory dysfunction had 2 points and white cell and platelet counts were removed. The c-statistic for Model 1 was 0.73 (95% CI 0.70, 0.77) and for Model 2 0.71 (95% CI 0.68, 0.75). CONCLUSIONS We present a VTE risk assessment model for use in medical inpatients. The score is simple and relies on information known at the time of admission and typically collected in all medical inpatients. External validation is needed.
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Affiliation(s)
- N A Zakai
- University of Vermont College of Medicine and Fletcher Allen Health Care, Colchester, VT 05446, USA.
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Hogg K, Hinchliffe E, Haslam S, Sethi B, Carrier M, Lecky F. Predicting short term mortality after investigation for venous thromboembolism. Thromb Res 2013; 131:e141-6. [PMID: 23415412 DOI: 10.1016/j.thromres.2013.01.030] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Revised: 12/17/2012] [Accepted: 01/24/2013] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Deaths following diagnosis of venous thromboembolism (VTE) often result from another concurrent illness. The specificity of mortality markers predicting death from pulmonary embolism is unknown. The aim of this analysis was to compare blood predictors of death in patients with confirmed VTE to patients with negative investigations for VTE. MATERIALS AND METHODS Consecutive patients investigated for VTE were prospectively consented from a single hospital over 9months. VTE was diagnosed and excluded with a standard diagnostic algorithm. Blood was drawn for biomarker analysis and analyzed in batches for NT-proBNP, high sensitivity troponin T, C-reactive protein (CRP), fatty acid binding protein (FABP) and ischemia modified albumin (IMA). Participants were followed for 3months. The cohort was analyzed in two groups: those diagnosed with VTE and those who had thrombosis excluded. Regression analysis for 3-month mortality was performed for each group. RESULTS 16/153 patients diagnosed with VTE died within three months (10.5%) as did 23/606 patients who had negative investigations for VTE (3.8%). Predictors for death following VTE included cancer, NT-proBNP, troponin T, FABP, and Hb<95g/L. NT-proBNP>500pg/ml in acute cancer associated VTE predicted death with C-statistic of 0.89 (0.80-0.99). Cancer, NT-proBNP and troponin T also predicted death in patients with negative investigations for VTE. CONCLUSION Several blood markers are not specific for death from PE and may be surrogate markers of global declining health.
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Affiliation(s)
- Kerstin Hogg
- The Manchester Academic Health Sciences Centre, Manchester, UK.
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Robin X, Turck N, Hainard A, Tiberti N, Lisacek F, Sanchez JC, Müller M. PanelomiX: A threshold-based algorithm to create panels of biomarkers. TRANSLATIONAL PROTEOMICS 2013. [DOI: 10.1016/j.trprot.2013.04.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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123
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Kurakina EA, Duplyakov DV, Khokhlunov SM, Kozupitsa GS. Predictive value of syncope in pulmonary embolism. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2012. [DOI: 10.15829/1728-8800-2012-5-49-54] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Aim. To assess the predictive value of syncope in the clinical course of pulmonary thromboembolism (PTE). Material and methods. The study included 117 PTE patients (62 men and 55 women; mean age 51,86±13,4 years). High and intermediate risk of fatal outcome was observed in 37 and 80 patients, respectively. In all participants, PTE diagnosis was verified by pulmonary artery (PA) computed tomography. All patients were divided into two groups: Group I (n=35) with syncope registered 1-30 days ago (median time 1 day) and Group II (n=82) without syncope. The groups were comparable by age, gender, time of the clinical onset, clinical risk of PTE, and PA pressure levels. However, in Group I patients, the prevalence of high risk of fatal outcome was twice as high as in Group II participants (45,7% vs. 25,6%; p=0,032). To compare the thrombolysis therapy (TLT) independent levels of in-hospital mortality, the two TLT-free subgroups – 1 (14 patients with syncope) and 2 (58 patients without syncope) – were identified. Results. Syncope was associated with massive PA embolism (60% in Group I vs. 39% in Group II; p=0,036), often accompanied by shock/ hypotension (49% vs. 28%, respectively; p=0,032). Group I patients required TLT twice as often as Group II subjects (p=0,001), which resulted in reduced in-hospital mortality levels among individuals with syncope (p=0,048). Overall, both groups did not differ significantly by the levels of in-hospital mortality, while syncope patients demonstrated a tendency towards increased mortality (14,2% and 8,5%; p=0,35). However, in the absence of TLT, mortality levels reached 28,5% (4/14) in Subgroup 1 and 8,6% (8/58) in Subgroup 2 (p=0,042). Conclusion. Syncope in patients with possible PTE should be regarded as a marker of high risk of in-hospital death, due to a high prevalence of embolism in the PA trunk and main branches. TLT could improve the inhospital prognosis. To clarify the issue of prognostic value of syncope in PTE, further studies are necessary.
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Affiliation(s)
| | - D. V. Duplyakov
- Samara Regional Clinical Cardiology Dispanser; Samara State Medical University
| | - S. M. Khokhlunov
- Samara Regional Clinical Cardiology Dispanser; Samara State Medical University
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124
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Clinical probability of pulmonary embolism: Comparison of different scoring systems. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2012. [DOI: 10.1016/j.ejcdt.2012.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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125
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Affiliation(s)
- Katherine Potts
- North Bristol NHS Trust, Clinical Investigations Unit, Southmead Hospital, Southmead Road, BS10 5NB
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126
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Bauersachs RM. Clinical presentation of deep vein thrombosis and pulmonary embolism. Best Pract Res Clin Haematol 2012; 25:243-51. [DOI: 10.1016/j.beha.2012.07.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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127
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Le Gal G, Carrier M, Rodger M. Clinical decision rules in venous thromboembolism. Best Pract Res Clin Haematol 2012; 25:303-17. [DOI: 10.1016/j.beha.2012.06.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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128
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Risk-benefit analysis of pulmonary CT angiography in patients with suspected pulmonary embolus. AJR Am J Roentgenol 2012; 198:1332-9. [PMID: 22623545 DOI: 10.2214/ajr.10.6329] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE The objective of our study was to estimate the mortality benefit-to-risk ratio of pulmonary CT angiography (CTA) by setting (ambulatory [emergency department or outpatient] or inpatient), age, and sex. MATERIALS AND METHODS A retrospective evaluation of 1424 consecutive pulmonary CTA examinations was performed and the following information was recorded: examination setting, patient age, patient sex, pulmonary CTA interpretation for pulmonary embolus (PE), and CT radiation exposure (dose-length product). We estimated mortality benefit of pulmonary CTA by multiplying the rate of positive pulmonary CTA examinations by published estimates of mortality of untreated PE in ambulatory and inpatient settings. We estimated the lifetime attributable risk of cancer mortality due to radiation from pulmonary CTA by calculating the estimated effective dose and using sex-specific polynomial equations derived from the Biological Effects of Ionizing Radiation VII report. We calculated benefit-to-risk ratios by dividing the mortality benefit of preventing a fatal PE by the mortality risk of a radiation-induced cancer. RESULTS Pulmonary CTA diagnosed PE in 188 of 1424 patients (13.2%). Both inpatients (101/723, 14.0%) and emergency department patients (74/509, 14.5%) had significantly higher rates of PE than outpatients (13/192 [6.8%]). Males received significantly (p = 0.02451) higher radiation dose (9.7 mSv) than females (8.4 mSv), but males had a significantly (p < 0.0001) lower lifetime attributable risk of cancer mortality than females. Assuming an untreated PE mortality rate of 5% for ambulatory patients and 30% for inpatients, the benefit-to-risk ratio ranged from 25 for ambulatory patients to 187 for inpatients. Ambulatory women had the lowest benefit-to-risk ratio. CONCLUSION The benefit-to-risk ratio of pulmonary CTA in patients with suspected PE ranges from 25 to 187 and can be increased by optimizing the radiation dose.
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130
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den Exter PL, Klok FA, Huisman MV. Diagnosis of pulmonary embolism: Advances and pitfalls. Best Pract Res Clin Haematol 2012; 25:295-302. [PMID: 22959546 DOI: 10.1016/j.beha.2012.06.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The signs and symptoms of patients with pulmonary embolism (PE) form a wide spectrum and considerably overlap with other cardiopulmonary diseases. Timely recognizing of this disease therefore remains challenging, but is of vital importance to avoid PE-related morbidity and mortality. To aid and standardize the initial diagnostic approach of patients with suspected PE, clinical probability rules have been developed and simplified for use in clinical practice. It has been demonstrated by clinical outcome studies that it is safe and of high clinical utility to exclude PE on the basis of an unlikely clinical probability and a normal D-dimer test result. For the remaining patients with suspected PE, imaging tests are required. The introduction of multi-detector computed tomographic pulmonary angiography (MD-CTA) has significantly improved the detection of PE, and this test is now regarded as the imaging test of first choice. This review will focus on recent advances and pitfalls that remain in the diagnostic work-up of patients with suspected acute PE.
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Affiliation(s)
- Paul L den Exter
- Department of Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, The Netherlands.
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131
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Geske JB, Smith SB, Morgenthaler TI, Mankad SV. Care of patients with acute pulmonary emboli: a clinical review with cardiovascular focus. Expert Rev Cardiovasc Ther 2012; 10:235-50. [PMID: 22292879 DOI: 10.1586/erc.11.179] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Acute pulmonary embolism (PE) is a common, multidisciplinary disease with substantial associated morbidity, mortality and healthcare expense. In this article we present a succinct review of diagnostic tools, risk stratification and medical therapies for cardiovascular care of patients with acute PE. While pulmonary angiography remains the 'gold standard' for diagnosis, a host of diagnostic modalities, interpreted in the setting of clinical probability, are available for patient assessment, including ECG, chest radiography, D-dimer, lower-extremity venous ultrasound, ventilation-perfusion scans, computed tomography and magnetic resonance angiography, and echocardiography, each with associated value. Diagnostic algorithms incorporate multiple tools in order to obtain a more comprehensive evaluation. Therapeutic anticoagulation remains the mainstay of therapy in PE. In massive PE, utilization of thrombolysis is reasonable in the absence of contraindications. Submassive PE, characterized by right ventricular dysfunction as assessed by echocardiography and ECG, is associated with higher mortality. Use of thrombolysis in submassive PE remains controversial. Catheter-directed therapies are emerging as an added approach to acute PE and have the potential to improve outcomes in PE. Use of inferior vena cava filters should be pursued in a select patient population as they serve to reduce recurrent acute PE; however, they are associated with more frequent deep venous thrombosis and provide no mortality benefit. In risk-stratified hemodynamically stable patients, an outpatient management strategy inclusive of therapeutic anticoagulation and careful clinical follow-up may be appropriate.
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Affiliation(s)
- Jeffrey B Geske
- Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA.
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132
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Imaging of pregnant and lactating patients: part 2, evidence-based review and recommendations. AJR Am J Roentgenol 2012; 198:785-92. [PMID: 22451542 DOI: 10.2214/ajr.11.8223] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The objectives of this article are to discuss the current evidence-based recommendations regarding the use of diagnostic imaging in the evaluation of pulmonary embolism, appendicitis, urolithiasis, and cholelithiasis during pregnancy. CONCLUSION Diagnostic imaging should be performed during pregnancy only with an understanding of the maternal and fetal risks and benefits, the comparative advantages of different modalities, and the unique anatomic and physiologic issues associated with pregnancy.
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Abstract
Pulmonary embolism (PE) remains one of the most challenging medical diseases in the emergency department. PE is a potentially life threatening diagnosis that is seen in patients with chest pain and/or dyspnea but can span the clinical spectrum of medical presentations. In addition, it does not have any particular clinical feature, laboratory test, or diagnostic modality that can independently and confidently exclude its possibility. This article offers a review of PE in the emergency department. It emphasizes the appropriate determination of pretest probability, the approach to diagnosis and management, and special considerations related to pregnancy and radiation exposure.
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Affiliation(s)
- David W Ouellette
- Department of Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada.
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134
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Tapson VF. Advances in the diagnosis and treatment of acute pulmonary embolism. F1000 MEDICINE REPORTS 2012; 4:9. [PMID: 22619694 PMCID: PMC3357009 DOI: 10.3410/m4-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Over the past two decades, considerable progress in technology and clinical research methods have led to advances in the diagnosis, treatment and prevention of acute venous thromboembolism. Despite this, however, the diagnosis is still often missed and preventive methods are often ignored. Published guidelines are useful, but are limited by the existing evidence base so that controversies remain with regard to topics such as duration of anticoagulation, indications for placement and removal of inferior vena caval filters, and when and how to administer thrombolytic therapy. The morbidity and mortality of this disease remain high, particularly when undiagnosed. While preventive approaches remain crucial, the focus of this review is on the diagnostic and therapeutic approach to acute venous thromboembolism, with an emphasis on acute pulmonary embolism.
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Affiliation(s)
- Victor F Tapson
- Division of Pulmonary and Critical Care Director, Center for Pulmonary Vascular Disease, Duke University Medical Center Durham, NC 27710 USA
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135
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Diagnostic approach to deep venous thrombosis and pulmonary embolism in the critical care setting. Crit Care Clin 2012; 27:841-67, vi. [PMID: 22082517 DOI: 10.1016/j.ccc.2011.08.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Considerable progress has been made during the last 30 years in the prevention, diagnosis, and therapy of venous thromboembolism. This article discusses the epidemiology, pathophysiology, and clinical presentation of the disease as well as the diagnostic uncertainty that exists in the critical care setting. Diagnostic approaches for deep venous thrombosis and pulmonary embolism are considered, including clinical prediction rules, D-dimer, contrast venography, duplex ultrasonography, computed tomographic angiography and venography, magnetic resonance imaging, ventilation–perfusion scanning, chest radiograph, arterial blood gases, electrocardiography, and echocardiography.
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136
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Wong DD, Ramaseshan G, Mendelson RM. Comparison of the Wells and Revised Geneva Scores for the diagnosis of pulmonary embolism: an Australian experience. Intern Med J 2012; 41:258-63. [PMID: 20214691 DOI: 10.1111/j.1445-5994.2010.02204.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND/AIMS Clinical prediction rules form an integral component of guidelines on the diagnostic approach to pulmonary embolism (PE). The Wells Score is commonly used but is subjective, while the newer Revised Geneva Score is based entirely on objective variables. The aim of this study was to compare the diagnostic accuracy of the Wells and Revised Geneva Scores for the diagnosis of PE. METHODS Patients presenting to the emergency department with clinically suspected PE and referred for CT pulmonary angiogram or ventilation/perfusion scintigraphy were evaluated. The Wells and Revised Geneva Scores were calculated on the same cohort of patients and dichotomized into low and intermediate/high probability groups. The sensitivities and specificities were compared using McNemar's test. Overall accuracy was determined using receiver operator characteristic curve analysis. RESULTS A total of 98 consecutive patients was included. The overall prevalence of PE was 15.3%. The frequency of PE in the low, intermediate and high probability groups was similar for both clinical prediction rules. Compared with the Revised Geneva Score, the Wells Score showed a lower sensitivity with borderline significance (46.7% vs 80.0%, P= 0.06) and a significantly higher specificity (67.5% vs 47.0%, P= 0.002). The overall accuracy of both rules was similar (P= 0.617). CONCLUSION Using the accepted guidelines in which a high pretest probability leads to further imaging and a low probability leads to a D-dimer blood test, use of the more specific Wells Score could safely reduce the number of unnecessary scans. This would need to be confirmed with larger, prospective trials.
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Affiliation(s)
- D D Wong
- Department of Diagnostic and Interventional Radiology, Royal Perth Hospital, Perth, Western Australia, Australia
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137
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Gex G, Gerstel E, Righini M, LE Gal G, Aujesky D, Roy PM, Sanchez O, Verschuren F, Rutschmann OT, Perneger T, Perrier A. Is atrial fibrillation associated with pulmonary embolism? J Thromb Haemost 2012; 10:347-51. [PMID: 22212132 DOI: 10.1111/j.1538-7836.2011.04608.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
BACKGROUND A pulmonary embolism (PE) is thought to be associated with atrial fibrillation (AF). Nevertheless, this association is based on weak data. OBJECTIVES To assess whether the presence of AF influences the clinical probability of PE in a cohort of patients with suspected PE and to confirm the association between PE and AF. PATIENTS/METHODS We retrospectively analyzed the data from two trials that included 2449 consecutive patients admitted for a clinically suspected PE. An electrocardiography (ECG) was systematically performed and a PE was diagnosed by computer tomography (CT). The prevalence of AF among patients with or without a PE was compared in a multivariate logistic regression model. RESULTS The prevalence of PE was 22.8% (519/2272) in patients without AF and 18.8% (25/133) in patients with AF (P = 0.28). After adjustment for confounding factors, AF did not significantly modify the probability of PE (odds ratio [OR] 0.68, 95% confidence interval [CI] 0.42-1.11). However, when PE suspicion was based on new-onset dyspnea, AF significantly decreased the probability of PE (OR 0.47, 95% CI 0.26-0.84). If isolated chest pain without dyspnea was the presenting complaint, AF tended to increase the probability of PE (OR 2.42, 95% CI 0.97-6.07). CONCLUSIONS Overall, the presence of AF does not increase the probability of PE when this diagnosis is suspected. Nevertheless, when PE suspicion is based on new-onset dyspnea, AF significantly decreases the probability of PE, as AF may mimic its clinical presentation. However, in patients with chest pain alone, AF tends to increase PE probability.
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Affiliation(s)
- G Gex
- Division of General Internal Medicine, Geneva University Hospital, Geneva, Switzerland.
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138
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Guttman J, Dankoff J. Critical predictors of pulmonary embolism. CAN J EMERG MED 2012; 14:120-3. [DOI: 10.2310/8000.2012.110553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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139
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Patocka C, Nemeth J. Pulmonary Embolism in Pediatrics. J Emerg Med 2012; 42:105-16. [DOI: 10.1016/j.jemermed.2011.03.006] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2010] [Revised: 08/18/2010] [Accepted: 03/17/2011] [Indexed: 11/29/2022]
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Kline JA, Corredor DM, Hogg MM, Hernandez J, Jones AE. Normalization of vital signs does not reduce the probability of acute pulmonary embolism in symptomatic emergency department patients. Acad Emerg Med 2012; 19:11-7. [PMID: 22251189 DOI: 10.1111/j.1553-2712.2011.01253.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES In a patient with symptoms of pulmonary embolism (PE), the presence of an elevated pulse, respiratory rate, shock index, or decreased pulse oximetry increases pretest probability of PE. The objective of this study was to evaluate if normalization of an initially abnormal vital sign can be used as evidence to lower the suspicion for PE. METHODS This was a prospective, noninterventional, single-center study of diagnostic accuracy conducted on adults presenting to an academic emergency department (ED), with at least one predefined symptom or sign of PE and one risk factor for PE. Clinical data, including the first four sets of vital signs, were recorded while the patient was in the ED. All patients underwent computed tomography pulmonary angiography (CTPA) and had 45-day follow-up as criterion standards. Diagnostic accuracy of each vital sign (pulse rate, respiratory rate, shock index, pulse oximetry) at each time was examined by the area under the receiver operating characteristic curve (AUC). RESULTS A total of 192 were enrolled, including 35 (18%) with PE. All patients had vital signs at triage, and 174 (91%), 135 (70%), and 106 (55%) had second to fourth sets of vital signs obtained, respectively. The initial pulse oximetry reading had the highest AUC (0.63, 95% confidence interval [CI] = 0.50 to 0.76) for predicting PE, and no other vital sign at any point had an AUC over 0.60. Among patients with an abnormal pulse rate, respiratory rate, shock index, or pulse oximetry at triage that subsequently normalized, the prevalences of PE were 18, 14, 19, and 33%, respectively. CONCLUSIONS Clinicians should not use the observation of normalized vital signs as a reason to forego objective testing for symptomatic patients with a risk factor for PE.
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Affiliation(s)
- Jeffrey A Kline
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC, USA.
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141
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Abstract
Lung failure is the most common organ failure seen in the intensive care unit. The pathogenesis of acute respiratory failure (ARF) can be classified as (1) neuromuscular in origin, (2) secondary to acute and chronic obstructive airway diseases, (3) alveolar processes such as cardiogenic and noncardiogenic pulmonary edema and pneumonia, and (4) vascular diseases such as acute or chronic pulmonary embolism. This article reviews the more common causes of ARF from each group, including the pathological mechanisms and the principles of critical care management, focusing on the supportive, specific, and adjunctive therapies for each condition.
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Affiliation(s)
- Rob Mac Sweeney
- Centre for Infection and Immunity, Queens University Belfast, Belfast, Northern Ireland
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142
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Warren DJ, Matthews S. Pulmonary embolism: investigation of the clinically assessed intermediate risk subgroup. Br J Radiol 2011; 85:37-43. [PMID: 21937613 DOI: 10.1259/bjr/17451818] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVES The simplified Wells pre-test probability scoring algorithm for pre-investigation evaluation of pulmonary emboli (PE) is a commonly utilised and validated assessment tool. We sought to identify whether use of a dichotomised scoring system altered the overall negative predictive value (NPV) in patients referred for CT pulmonary angiography (CTPA) assessment of suspected PE. METHODS Prospective data collection of all patients referred for CTPA evaluation of suspected acute PE during a 3 year period was carried out. Pre-test risk stratification was performed according to simplified Wells criteria in conjunction with plasma d-Dimer (Bio-Pool and IL test) estimation. Retrospective dichotomisation was also performed. RESULTS 2531 patients were investigated for suspected acute PE; acute thromboemboli were confirmed in 22.7%. The overall NPV for negative d-Dimer and intermediate pre-test probability (PTP) was 98.9% [95% confidence interval (CI) 96.3-99.7%]; with retrospective dichotomisation, the NPV for the PE unlikely group was 99.0% (95% CI 94.8-99.8%). Implementation of dichotomised scoring, excluding PE unlikely with negative d-Dimer cases from further imaging, would have yielded a 4% reduction in CTPA referral pathway imaging at our institution. CONCLUSION We demonstrate no significant difference between exclusion in the intermediate subgroup and the retrospectively dichotomised PE unlikely group and demonstrate the high negative predictive power of the Bio-Pool and IL tests in conjunction with the Wells PTP tool. Prior to implementation of new guidelines for exclusion of patients with suspected PE from further imaging, hospitals should audit their own practice and validate the d-Dimer assay utilised at their institution.
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Affiliation(s)
- D J Warren
- Radiology Department, Royal Hallamshire Hospital, Sheffield NHS Teaching Hospitals Trust, Sheffield, UK.
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143
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Fesmire FM, Brown MD, Espinosa JA, Shih RD, Silvers SM, Wolf SJ, Decker WW. Critical issues in the evaluation and management of adult patients presenting to the emergency department with suspected pulmonary embolism. Ann Emerg Med 2011; 57:628-652.e75. [PMID: 21621092 DOI: 10.1016/j.annemergmed.2011.01.020] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
This clinical policy from the American College of Emergency Physicians is the revision of a 2003 clinical policy on the evaluation and management of adult patients presenting with suspected pulmonary embolism (PE).(1) A writing subcommittee reviewed the literature to derive evidence-based recommendations to help clinicians answer the following critical questions: (1) Do objective criteria provide improved risk stratification over gestalt clinical assessment in the evaluation of patients with possible PE? (2) What is the utility of the Pulmonary Embolism Rule-out Criteria (PERC) in the evaluation of patients with suspected PE? (3)What is the role of quantitative D-dimer testing in the exclusion of PE? (4) What is the role of computed tomography pulmonary angiogram of the chest as the sole diagnostic test in the exclusion of PE? (5) What is the role of venous imaging in the evaluation of patients with suspected PE? (6) What are the indications for thrombolytic therapy in patients with PE? Evidence was graded and recommendations were given based on the strength of the available data in the medical literature.
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144
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Huckins DS, Price LL, Gilley K. Utilization and yield of chest computed tomographic angiography associated with low positive D-dimer levels. J Emerg Med 2011; 43:211-20. [PMID: 21764536 DOI: 10.1016/j.jemermed.2011.05.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2010] [Revised: 11/17/2010] [Accepted: 05/23/2011] [Indexed: 11/18/2022]
Abstract
BACKGROUND It is unclear to what degree broadly applied D-dimer testing combined with a low threshold for imaging with even minimally positive results may be contributing to the utilization of chest computed tomographic angiography (CTA). STUDY OBJECTIVES To determine what proportion of chest CTAs for suspected pulmonary embolism (PE) were performed in the setting of minimally elevated D-dimer levels, and to determine the prevalence of PE in those patients when stratified by clinical risk. METHODS Retrospective chart review of all patients who had chest CTA for the evaluation of suspected PE during the years 2002-2006 in a suburban community teaching hospital emergency department. RESULTS There were 1136 eligible patient visits, of which 353 (31.1%) were found to have D-dimer levels in the low positive range (0.5-0.99 μg/mL). Of these 353 patients, 9 (2.6%; 95% confidence interval [CI] 0.9-4.2%) were diagnosed with PE. There were also 109 patients (9.6%) who had normal D-dimer levels (<0.5 μg/mL). Two of these 109 (1.8%; 95% CI 0-4.2%) were diagnosed with PE. When stratified by the Pulmonary Embolism Rule-out Criteria, 99 of 353 patients with low positive D-dimer levels (28.0%; 95% CI 23.4-32.7%), and 14 of 109 with normal D-dimer levels (12.8%; 95% CI 6.6-19.1%) were classified as low risk, none of whom had PE. CONCLUSIONS Nearly one-third of all chest CTAs were done for patients with minimally elevated D-dimer levels, and another 9.6% for patients with normal D-dimer levels with very low yield. Further research to define clinical criteria identifying patients with minimal risk of PE despite low positive D-dimer levels represents an opportunity to improve both patient safety and utilization efficiency of chest CTA.
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Affiliation(s)
- David S Huckins
- Department of Emergency Medicine, Newton-Wellesley Hospital, Newton, Massachusetts 02462, USA
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Does a clinical decision rule using D-dimer level improve the yield of pulmonary CT angiography? AJR Am J Roentgenol 2011; 196:1059-64. [PMID: 21512071 DOI: 10.2214/ajr.10.4200] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The objective of our study was to evaluate the impact of incorporating a mandatory clinical decision rule and selective d-dimer use on the yield of pulmonary CT angiography (CTA). MATERIALS AND METHODS Guidelines incorporating a clinical decision rule (Wells score: range, 0-12.5) and a highly sensitive d-dimer assay as decision points were placed into a computerized order entry menu. From December 2006 through November 2008, 261 pulmonary CTA examinations of 238 men and 14 women (mean age ± SD, 65 ± 12 years; range, 31-92 years) were performed. Eight patients underwent more than one pulmonary CTA examination. Charts were reviewed. The results of pulmonary CTA, the clinical decision rule, and d-dimer level (if obtained) were analyzed with the Student t test, chi-square test, or other comparisons using statistical software (MedCalc, version 11.0). RESULTS Of the pulmonary CTA examinations, 16.5% (43/261) were positive for pulmonary embolism (PE) compared with 3.1% (6/196) during the previous 2 years. The mean clinical decision rule score and mean d-dimer level were 5.5 ± 2.4 (SD) and 4956 ± 2892 ng/mL, respectively, for those with PE compared with 4.5 ± 2.1 and 2398 ± 2100 ng/mL for those without PE (both, p < 0.01). The negative predictive value of a clinical decision rule score of 4 or less and d-dimer level of less than 1000 ng/mL was 1.0. A clinical decision rule of greater than 4 and a higher d-dimer level were better predictors for PE, especially a d-dimer level of greater than 3000 ng/mL (odds ratio = 6.69; 95% CI = 2.72-16.43). CONCLUSION Guidelines combining a clinical decision rule with d-dimer level significantly improved the utilization of pulmonary CTA and positive yield for PE.
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Effectiveness and Acceptability of a Computerized Decision Support System Using Modified Wells Criteria for Evaluation of Suspected Pulmonary Embolism. Ann Emerg Med 2011; 57:613-21. [DOI: 10.1016/j.annemergmed.2010.09.018] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2010] [Revised: 09/06/2010] [Accepted: 09/21/2010] [Indexed: 11/15/2022]
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Yamasaki M, Sumi Y, Sakakibara Y, Tamaoka M, Miyazaki Y, Arai H, Kojima K, Itoh F, Amano T, Yoshizawa Y, Inase N. Pulmonary Artery Leiomyosarcoma Diagnosed without Delay. Case Rep Oncol 2011; 4:287-98. [PMID: 21734884 PMCID: PMC3124463 DOI: 10.1159/000328994] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
A 63-year-old female presented with abnormal lung shadows but had, apart from this, few symptoms. Computed tomography (CT) revealed multiple nodules and blockage of the pulmonary artery. She was immediately diagnosed with pulmonary artery sarcoma based on a careful differential diagnosis and underwent surgery. Her tumor was pathologically diagnosed as leiomyosarcoma (i.e. intimal sarcoma). Pulmonary artery sarcoma can be easily confounded with thromboembolism in a clinical setting and some cases are diagnosed post mortem only. In our case, clinical prediction scores (Wells score, Geneva score, and revised Geneva score) for the pulmonary embolism showed low probability. Moreover, chest CT showed uncommon findings for pulmonary thromboembolism, as the nodules were too big for thrombi. Because surgical resection can provide the only hope of long-term survival in cases of pulmonary artery sarcoma, clinicians should consider this possibility in the differential diagnosis of pulmonary embolism. Clinical prediction scores and CT findings might help to reach the correct diagnosis of pulmonary artery sarcoma.
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Affiliation(s)
- Motohisa Yamasaki
- Department of Integrated Pulmonology, Graduate School of Medical and Dental Science, Tokyo Medical and Dental University, Tokyo, Japan
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148
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Robert-Ebadi H, Righini M. [Diagnosis of pulmonary embolism]. Rev Mal Respir 2011; 28:790-9. [PMID: 21742240 DOI: 10.1016/j.rmr.2010.10.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2010] [Accepted: 10/09/2010] [Indexed: 11/18/2022]
Abstract
Nowadays the diagnosis of pulmonary embolism (PE) is based on a "diagnostic strategy" rather than a single test. The first step, after identifying patients with suspicion of PE, is to establish the pre-test clinical probability. Several scores are available to make a standardised and reproducible assessment of the clinical probability and these, therefore, represent valuable diagnostic tools. Indeed, it is the clinical probability that guides further investigation. In patients with low or intermediate clinical probability, PE can be safely ruled out by a negative D-dimer in approximately one-third of patients without additional imaging. In the case of a positive D-dimer or high clinical probability, CT pulmonary angiography is now the recommended imaging technique. However, lower limb venous compression ultrasound and ventilation/perfusion scans remain useful in patients with contraindications to CT; mainly those with renal insufficiency. In the presence of readily available and strongly validated diagnostic strategies, the challenge for the future will probably be better identification of patients in whom PE should be suspected.
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Affiliation(s)
- H Robert-Ebadi
- Service d'angiologie et d'hémostase, hôpitaux universitaires de Genève, Genève, Suisse.
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149
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Impact de la seniorisation et du rappel des bonnes indications sur la prescription d’examens d’hémostase aux urgences pour adultes. ANNALES FRANCAISES DE MEDECINE D URGENCE 2011. [DOI: 10.1007/s13341-011-0045-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Bertoletti L, Le Gal G, Aujesky D, Roy PM, Sanchez O, Verschuren F, Bounameaux H, Perrier A, Righini M. Prognostic value of the Geneva prediction rule in patients in whom pulmonary embolism is ruled out. J Intern Med 2011; 269:433-40. [PMID: 21198991 DOI: 10.1111/j.1365-2796.2010.02328.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The prognosis of patients in whom pulmonary embolism (PE) is suspected but ruled out is poorly understood. We evaluated whether the initial assessment of clinical probability of PE could help to predict the prognosis for these patients. DESIGN Retrospective analysis of data obtained during a prospective multicentre management study. SETTING Six general and teaching hospitals in Belgium, France and Switzerland. SUBJECTS In 1334 patients in whom PE was ruled out, 3-month mortality data were available (hospital readmission status was unknown for three patients) and clinical probability was evaluated with the revised Geneva score (RGS). MAIN OUTCOME MEASURES Three-month mortality and readmission rates. RESULTS Three-month mortality and readmissions rates were 3% and 19%, respectively and differed significantly depending on the RGS-determined PE probability group (P<0.001). When compared with patients presenting with a low probability, the risk of death after 3 months was higher in cases of intermediate or high RGS-based probability {odds ratio: 8.7 [95% confidence interval (CI): 2.7-28.5] and 22.6 (95%CI: 2.1-241.2), respectively}. The readmission risk increased with PE probability group (P<0.001). The main causes of death were cancer, respiratory failure and cardiovascular failure. In total, 86% of patients with low RGS-based probability were alive and had not been readmitted to hospital, whereas other patients had a twofold increased risk of death or readmission during the 3-month follow-up. The simplified Geneva score, calculated a posteriori, gave similar results. CONCLUSIONS Initial assessment of clinical probability may help to stratify prognosis of patients in whom PE has been ruled out. Patients with a low probability of PE have a good prognosis. Whether patients with higher probability might benefit from more vigilant care should be evaluated.
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Affiliation(s)
- L Bertoletti
- Division of Angiology and Haemostasis, Department of Internal Medicine, Geneva Faculty of Medicine, University of Geneva, Geneva, Switzerland
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