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Thomas SE, Weinberg I, Schainfeld RM, Rosenfield K, Parmar GM. Diagnosis of Pulmonary Embolism: A Review of Evidence-Based Approaches. J Clin Med 2024; 13:3722. [PMID: 38999289 PMCID: PMC11242034 DOI: 10.3390/jcm13133722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Revised: 06/10/2024] [Accepted: 06/20/2024] [Indexed: 07/14/2024] Open
Abstract
Venous thromboembolism, commonly presented as pulmonary embolism and deep-vein thrombosis, is a paramount and potentially fatal condition with variable clinical presentation. Diagnosis is key to providing appropriate treatment in a safe and timely fashion. Clinical judgment and assessment using clinical scoring systems should guide diagnostic testing, including laboratory and imaging modalities, for optimal results and to avoid unnecessary testing.
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Affiliation(s)
- Sneha E Thomas
- Vascular Medicine Section, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Ido Weinberg
- Vascular Medicine Section, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Robert M Schainfeld
- Vascular Medicine Section, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Kenneth Rosenfield
- Vascular Medicine Section, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Gaurav M Parmar
- Vascular Medicine Section, Massachusetts General Hospital, Boston, MA 02114, USA
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2
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Birrenkott DA, Kabrhel C, Dudzinski DM. Intermediate-Risk and High-Risk Pulmonary Embolism: Recognition and Management: Cardiology Clinics: Cardiac Emergencies. Cardiol Clin 2024; 42:215-235. [PMID: 38631791 DOI: 10.1016/j.ccl.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Pulmonary embolism (PE) is the third most common cause of cardiovascular death. Every specialty of medical practitioner will encounter PE in their patients, and should be prepared to employ contemporary strategies for diagnosis and initial risk-stratification. Treatment of PE is based on risk-stratification, with anticoagulation for all patients, and advanced modalities including systemic thrombolysis, catheter-directed therapies, and mechanical circulatory supports utilized in a manner paralleling PE severity and clinical context.
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Affiliation(s)
- Drew A Birrenkott
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Center for Vascular Emergencies, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Christopher Kabrhel
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Center for Vascular Emergencies, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - David M Dudzinski
- Center for Vascular Emergencies, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Cardiac Intensive Care Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
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3
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Hassine M, Kallala MY, Jamel A, Bouanene I, Bouchahda N, Mahjoub M, Memmi K, Ben Halima N, Gamra H. The impact of right bundle branch block and SIQIII-type patterns in determining risk levels in acute pulmonary embolism. F1000Res 2023; 12:545. [PMID: 38813350 PMCID: PMC11134142 DOI: 10.12688/f1000research.131758.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/12/2023] [Indexed: 05/31/2024] Open
Abstract
Background: Electrocardiography (ECG) findings in acute pulmonary embolism (PE) are known to be related to various right ventricular (RV) alterations. These abnormalities are not included in risk stratification algorithms despite emerging evidence of their association with patient outcomes. We aimed to analyze the impact of right bundle branch block (RBBB) and/or SIQIII patterns as indicators for determining the level of risk in patients with PE. Methods: We performed a retrospective cohort study including all patients with confirmed acute PE hospitalized from January 2008 to December 2019 in two tertiary care cardiology departments. The first ECG taken at admission was selected and the analysis focused on the presence of a complete or an incomplete RBBB and SIQIII-type patterns. Results: A total of 255 patients were divided into two groups: Group I (47.8%, n=122) included patients with PE without RBBB nor SIQIII patterns, and Group II (52.2%, n=133) included patients with RBBB and/or SIQIII patterns. Patients in group II presented significantly more frequently with acute right heart symptoms (45.1% vs. 18%, p<0.001) and cardiogenic shock at admission (31.6 vs. 4.1%, p<0.001). Echocardiographic parameters indicating right heart injury also occurred more significantly in group II patients (p<0.001). By univariate analysis, patients in group II were found to be significantly associated with in-hospital mortality (22.6 vs. 6.1%, p=0.002) and major cardiovascular events (MACEs) during hospitalization (43.3 vs. 13.7%, p<0.001). Multivariate logistic regression analysis identified five independent factors predictive of MACEs: SIQIII and/or RBBB, renal failure, positive troponin levels, RV dysfunction and right heart failure symptoms during initial presentation. Kaplan-Meier survival analysis identified the inclusion in Group II and the presence of SIQIII pattern as predictors of overall mortality (p<0.001). Conclusions: Our study suggests an important and independent prognostic value of RBBB and SIQIII patterns and their usefulness in determining the outcome of PE patients.
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Affiliation(s)
- Majed Hassine
- Cardiology A Department, Cardiothrombosis Research Laboratory, Fattouma Bourguiba University Hospital, Universite de Monastir, Monastir, Monastir, 5000, Tunisia
| | - Mohamed Yassine Kallala
- Cardiology A Department, Cardiothrombosis Research Laboratory, Fattouma Bourguiba University Hospital, Universite de Monastir, Monastir, Monastir, 5000, Tunisia
| | - Ahmed Jamel
- Cardiology Department of Kairouan, Universite de Sousse, Sousse, Sousse, 5030, Tunisia
| | - Ines Bouanene
- Department of Epidemiology and Preventive Medicine, Fattouma Bourguiba Hospital, Universite de Monastir, Monastir, Monastir, 5000, Tunisia
| | - Nidhal Bouchahda
- Cardiology A Department, Cardiothrombosis Research Laboratory, Fattouma Bourguiba University Hospital, Universite de Monastir, Monastir, Monastir, 5000, Tunisia
| | - Marouen Mahjoub
- Cardiology A Department, Cardiothrombosis Research Laboratory, Fattouma Bourguiba University Hospital, Universite de Monastir, Monastir, Monastir, 5000, Tunisia
| | - Kais Memmi
- Cardiology A Department, Cardiothrombosis Research Laboratory, Fattouma Bourguiba University Hospital, Universite de Monastir, Monastir, Monastir, 5000, Tunisia
| | - Najeh Ben Halima
- Cardiology Department of Kairouan, Universite de Sousse, Sousse, Sousse, 5030, Tunisia
| | - Habib Gamra
- Cardiology A Department, Cardiothrombosis Research Laboratory, Fattouma Bourguiba University Hospital, Universite de Monastir, Monastir, Monastir, 5000, Tunisia
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4
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Oh JK, Park JH. Role of echocardiography in acute pulmonary embolism. Korean J Intern Med 2023:kjim.2022.273. [PMID: 36587934 DOI: 10.3904/kjim.2022.273] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 11/28/2022] [Indexed: 01/03/2023] Open
Abstract
Although pulmonary embolism (PE)-related mortality rate has decreased because of prompt diagnosis and effective therapy use, acute PE remains a potentially lethal disease. Due to its increasing prevalence, clinicians should pay attention to diagnosing and managing patients with acute PE. Echocardiography is the most commonly used method for diagnosing and managing acute PE; it also provides clues about hemodynamic instability in an emergency situation. It has been validated in the early risk stratification and impacts management strategies for treating acute PE. In hemodynamically unstable patients with acute PE, echocardiographic detection of right ventricular dysfunction is an indication for administering thrombolytics. In this review article, we discuss the role of echocardiography in the diagnosis and management of patients with acute PE.
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Affiliation(s)
- Jin Kyung Oh
- Division of Cardiology, Department of Internal Medicine, Chungnam National University Sejong Hospital, Chungnam National University College of Medicine, Sejong, Korea
| | - Jae-Hyeong Park
- Department of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea
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5
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Hijikata S, Sakurai K, Takahashi Y, Azegami K. Successful visualization of pulmonary embolism using fluoroscopic video analysis in a patient with iodine contrast allergy: a case report. Eur Heart J Case Rep 2022; 6:ytac416. [PMID: 36320379 PMCID: PMC9606237 DOI: 10.1093/ehjcr/ytac416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 04/08/2022] [Accepted: 10/10/2022] [Indexed: 11/05/2022]
Abstract
Background Contrast-enhanced computed tomography (CT) is commonly used to diagnose pulmonary embolism (PE). However, a history of iodine contrast allergy presents a dilemma in the management of patients with PE. As an alternative approach, X-ray fluoroscopic video analysis has been recently reported to be useful in diagnosing PE. Case summary A 78-year-old man with dyspnoea of 1-month duration visited our hospital. His oxygen saturation was 89%, and echocardiography demonstrated right heart strain. We could not perform contrast-enhanced CT because the patient had a history of contrast allergy and refused to undergo premedicated contrast CT with anti-histamine and/or corticosteroid. Therefore, a video analysis of pulmonary circulation using dynamic chest X-ray (DCR) was performed. The reconstructed pseudo-colour video showed defects of pulmonary circulation in both lung areas. We diagnosed PE and started anticoagulant therapy. Multiple segmental defects were also observed in pulmonary perfusion scintigraphy on Day 3, which confirmed the diagnosis of PE. He was discharged on Day 9, and an improvement of the pulmonary circulation as assessed with DCR was observed. He had no symptoms at the last follow-up visit at 1 year after discharge. Discussion We describe the successful visualization of PE using DCR in a patient with iodine contrast allergy.
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Affiliation(s)
| | - Kaoru Sakurai
- Department of Cardiovascular Medicine, Shin-yurigaoka General Hospital, 255 Furusawatsuko, Asao-ward, Kawasaki, Kanagawa 180-8610, Japan
| | - Yoshihide Takahashi
- Department of Cardiovascular Medicine, Shin-yurigaoka General Hospital, 255 Furusawatsuko, Asao-ward, Kawasaki, Kanagawa 180-8610, Japan
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Remillard TC, Kodra A, Kim M. Diagnosis, Diagnostic Tools, and Risk Stratification for Contemporary Treatment of Pulmonary Embolism. Int J Angiol 2022; 31:150-154. [PMID: 36157099 PMCID: PMC9507591 DOI: 10.1055/s-0042-1756177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
Abstract
Pulmonary embolism (PE) is quite common and is associated with significant morbidity and mortality. It is estimated that it is the cause of approximately 100,000 annual deaths in the United States. With great variability in presenting symptoms of PE, poor recognition of PE can be fatal. As such, many risk scores have been created to identify the sickest patients. Choosing the appropriate imaging modality is also critical. Invasive pulmonary angiography was once the gold standard to establish the diagnosis. With the advent of nuclear imaging, V/Q scans, invasive angiography has been phased out for diagnosing acute PE. At present, the standard for diagnosis of acute PE is computed tomography pulmonary angiography. In select patient cohorts, nuclear studies remain the modality of choice. Once the diagnosis of acute PE is established, there is a broad spectrum of severity in outcome which has led to substantial focus and development of risk stratification prediction models. We will discuss making the proper diagnosis with contemporary diagnostic tools and risk stratifying patients with PE to receive the correct treatment.
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Affiliation(s)
- Taylor C. Remillard
- Department of Cardiology, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Arber Kodra
- Department of Cardiology, Lenox Hill Hospital, Northwell Health, New York, New York
- Department of Cardiothoracic Surgery, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Michael Kim
- Department of Cardiology, Lenox Hill Hospital, Northwell Health, New York, New York
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7
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Imagerie de l’embolie pulmonaire chez la femme enceinte. IMAGERIE DE LA FEMME 2022. [DOI: 10.1016/j.femme.2022.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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8
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Ye W, Chen X, Li X, Guo X, Gu W. Arterial partial pressure of oxygen and diffusion function as prognostic biomarkers for acute pulmonary embolism. Respir Med 2022; 195:106794. [PMID: 35240420 DOI: 10.1016/j.rmed.2022.106794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 02/23/2022] [Accepted: 02/24/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Risk stratification for acute pulmonary embolism (PE) ignores the roles of respiratory function and gas exchange. We aimed to identify the role of arterial partial pressure of oxygen (PO2) and diffusion function as prognostic biomarkers. METHODS We collected the data from hospitalised patients with acute PE. We used Spearman's correlation coefficient and Cox regression analysis to explore the clinical and prognostic values of PO2 and predicted percentage diffusing lung capacity for carbon monoxide (DLCO%pred) to predict the 30-day mortality. RESULTS We included 309 patients (mean age: 67.93 ± 13.31 years); 46.6% were men, and 12.62% were haemodynamically unstable. The 30-day all-cause mortality rates in the high-, intermediate high-, intermediate low-, and low-risk groups were 7.7%, 4.7%, 2.9%, and 0.0%, respectively (P < 0.05). PO2 (P = 0.012) and DLCO%pred (P = 0.036) were significantly different between the four risk groups. There were strong correlations between PO2, DLCO%pred, PO2*DLCO%pred, and other markers (P < 0.05), especially troponin I, N-terminal pro-brain natriuretic peptide, and systolic pulmonary artery pressure. PO2 and PO2*DLCO%pred were prognostic factors for death in haemodynamically stable patients (hazard ratio [HR] 0.618, 95% confidence interval [CI] 0.389-0.980, P = 0.041, and HR 0.501, 95% CI 0.26-0.96, P = 0.036, respectively). A lower PO2 (<8 kPa) was associated with a higher risk of mortality in all patients and in haemodynamically stable ones (HR 9.462, 95% CI 2.365-37.860, P = 0.001, and HR 6.597, 95% CI 1.102-39.495, P = 0.039, respectively). CONCLUSIONS PO2, PO2*DLCO%pred, and PO2 < 8 kPa were predictors of 30-day all-cause mortality in all patients and haemodynamically stable ones. TRIAL REGISTRATION ChiCTR2000030448.
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Affiliation(s)
- Wenjing Ye
- Department of Respiratory Medicine, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xi Chen
- Department of Respiratory Medicine, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xiaoming Li
- Department of Respiratory Medicine, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xuejun Guo
- Department of Respiratory Medicine, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
| | - Wen Gu
- Department of Respiratory Medicine, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
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9
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Kulka HC, Zeller A, Fornaro J, Wuillemin WA, Konstantinides S, Christ M. Acute Pulmonary Embolism–Its Diagnosis and Treatment From a Multidisciplinary Viewpoint. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 118:618-628. [PMID: 34382576 DOI: 10.3238/arztebl.m2021.0226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 12/31/2020] [Accepted: 04/28/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Physicians from many different specialties see patients suffering from acute pulmonary embolism (PE), which has an incidence of 39-115 cases per 100 000 persons per year. Because PE can be life-threatening, a rapid, targeted response is essential. METHODS This review is based on pertinent publications retrieved by a selective literature search of international databases, with particular attention to current guidelines and expert opinions. RESULTS Whenever PE is suspected, clinical assessment tools must be applied for risk stratification and diagnostic evaluation. The PERC (Pulmonary Embolism Rule-out Criteria) and the YEARS algorithm lead to more effective diagnosis. For hemodynamically unstable patients, bedside echocardiography is of high value and enables risk stratification. New oral anticoagulants have fewer hemorrhagic complications than vitamin K antagonists and are not inferior to them with respect to the risk of recurrent PE (hazard ratio 0.84-1.09). The duration of anticoagulation is set according to the risk of recurrence. Systemic thrombolysis is recommended for patients with a high-risk PE, in whom it significantly reduces mortality (odds ratio 0.53, number needed to treat 59). Surgical or interventional techniques can be considered if thrombolysis is contraindicated or unsuccessful. CONCLUSION Newly introduced diagnostic aids and algorithms simplify the diagnosis and treatment of acute PE while continuing to assure a high degree of patient safety.
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10
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Stolberg S, Mudawi D, Dean K, Cheng A, Barraclough R. Investigation and management of pulmonary embolism 1: a probability-based approach. Br J Hosp Med (Lond) 2021; 82:1-16. [PMID: 34338014 DOI: 10.12968/hmed.2021.0286a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Pulmonary embolism remains a common and potentially deadly disease, despite advances in diagnostic imaging, treatment and prevention. Managing pulmonary embolism requires a multifactorial approach involving risk stratification, determining appropriate diagnostics and selecting individualised therapy. This article reviews the pathophysiology, risk factors, clinical presentation, diagnostic evaluation and therapeutic management and early outpatient management of pulmonary embolism. The second part summarises pulmonary embolism in the setting of pregnancy, COVID-19, recurrent disease and chronic thromboembolic pulmonary hypertension.
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Affiliation(s)
- Stephanie Stolberg
- Department of Respiratory Medicine, Wythenshawe Hospital, Manchester, UK
| | - Dalia Mudawi
- Department of Respiratory Medicine, Wythenshawe Hospital, Manchester, UK
| | - Katrina Dean
- Department of Respiratory Medicine, Wythenshawe Hospital, Manchester, UK
| | - Andrew Cheng
- Department of Respiratory Medicine, Wythenshawe Hospital, Manchester, UK
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11
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Ventilation-Perfusion Scans After the COVID-19 Pandemic: Counterpoint-Ventilation Studies Are Here to Stay. AJR Am J Roentgenol 2021; 218:31-32. [PMID: 34161129 DOI: 10.2214/ajr.21.26383] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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12
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Nguyen ET, Hague C, Manos D, Memauri B, Souza C, Taylor J, Dennie C. Canadian Society of Thoracic Radiology/Canadian Association of Radiologists Best Practice Guidance for Investigation of Acute Pulmonary Embolism, Part 1: Acquisition and Safety Considerations. Can Assoc Radiol J 2021; 73:203-213. [PMID: 33781098 DOI: 10.1177/08465371211000737] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Acute pulmonary embolism (APE) is a well-recognized cause of circulatory system compromise and even demise which can frequently present a diagnostic challenge for the physician. The diagnostic challenge is primarily due to the frequency of indeterminate presentations as well as several other conditions which can have a similar clinical presentation. This often obliges the physician to establish a firm diagnosis due to the potentially serious outcomes related to this disease. Computed tomography pulmonary angiography (CTPA) has increasingly cemented its role as the primary investigation tool in this clinical context and is widely accepted as the standard of care due to several desired attributes which include great accuracy, accessibility, rapid turn-around time and the ability to suggest an alternate diagnosis when APE is not the culprit. In Part 1 of this guidance document, a series of up-to-date recommendations are provided to the reader pertaining to CTPA protocol optimization (including scan range, radiation and intravenous contrast dose), safety measures including the departure from breast and gonadal shielding, population-specific scenarios (pregnancy and early post-partum) and consideration of alternate diagnostic techniques when clinically deemed appropriate.
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Affiliation(s)
- Elsie T Nguyen
- Department of Radiology, Joint Department of Medical Imaging, Toronto General Hospital, University of Toronto, Ontario, Canada
| | - Cameron Hague
- Department of Radiology, University of British Columbia, Ontario, Canada
| | - Daria Manos
- Department of Diagnostic Radiology, Dalhousie University, Ontario, Canada
| | - Brett Memauri
- Department of Radiology, University of Manitoba, Cardiothoracic Sciences Division, St. Boniface General Hospital, Ontario, Canada
| | - Carolina Souza
- Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, Ontario, Canada
| | - Jana Taylor
- Department of Radiology, McGill University Health Centre, Ontario, Canada
| | - Carole Dennie
- Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, Ontario, Canada.,Department of Radiology, University of Ottawa, Ottawa Hospital Research Institute, Ontario, Canada
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Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, Huisman MV, Humbert M, Jennings CS, Jiménez D, Kucher N, Lang IM, Lankeit M, Lorusso R, Mazzolai L, Meneveau N, Ní Áinle F, Prandoni P, Pruszczyk P, Righini M, Torbicki A, Van Belle E, Zamorano JL. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J 2021; 41:543-603. [PMID: 31504429 DOI: 10.1093/eurheartj/ehz405] [Citation(s) in RCA: 2045] [Impact Index Per Article: 681.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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14
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Elias A, Aronson D. Risk of Acute Kidney Injury after Intravenous Contrast Media Administration in Patients with Suspected Pulmonary Embolism: A Propensity-Matched Study. Thromb Haemost 2020; 121:800-807. [PMID: 33302305 DOI: 10.1055/s-0040-1721387] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Although computed tomography pulmonary angiography (CTPA) is the preferred diagnostic procedure in patients with suspected pulmonary embolism (PE), some patients undergo ventilation/perfusion (V/Q) lung scan due to concern of contrast-associated acute kidney injury (AKI). METHODS The study used a cohort of 4,565 patients with suspected PE. Patients who received contrast during CTPA were compared with propensity score-matched unexposed control patients who underwent V/Q lung scanning. AKI was defined as ≥50% increase in serum creatinine during the first 72 hours after either CTPA or V/Q lung scan. RESULTS Classification and regression tree analysis demonstrated that baseline creatinine was the strongest determinant of the decision to use CTPA. Propensity-score matching yielded 969 patient pairs. There were 44 AKI events (4.5%) in patients exposed to contrast media (CM) and 33 events (3.4%) in patients not exposed to CM (risk difference: 1.1%, 95% confidence interval [CI]: -0.6 to 2.9%; odds ratio [OR]: 1.39, 95% CI: 0.86-2.26; p = 0.18). Using different definitions for AKI and extending the time window for AKI diagnosis gave similar results. In a sensitivity analysis with the inverse probability weighting method, the OR for AKI in the CTPA versus V/Q scan was 1.14 (95% CI: 0.72-1.78; p = 0.58). CONCLUSION Intravenous contrast material administration was not associated with an increased risk of AKI in patients with suspected PE. Given the diagnostic superiority of CTPA, these results are reassuring with regard to the use of CTPE in patients with suspected PE perceived to be at risk for AKI.
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Affiliation(s)
- Adi Elias
- Department of Cardiology, Rambam Medical Center, Haifa, Israel.,B. Rappaport Faculty of Medicine, Technion Medical School, Haifa, Israel
| | - Doron Aronson
- Department of Cardiology, Rambam Medical Center, Haifa, Israel.,B. Rappaport Faculty of Medicine, Technion Medical School, Haifa, Israel
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15
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Stals MAM, Klok FA, Huisman MV. Diagnostic management of acute pulmonary embolism in special populations. Expert Rev Respir Med 2020; 14:729-736. [DOI: 10.1080/17476348.2020.1753505] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Milou A. M. Stals
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A. Klok
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Menno V. Huisman
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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16
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Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, Huisman MV, Humbert M, Jennings CS, Jiménez D, Kucher N, Lang IM, Lankeit M, Lorusso R, Mazzolai L, Meneveau N, Áinle FN, Prandoni P, Pruszczyk P, Righini M, Torbicki A, Van Belle E, Zamorano JL. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Respir J 2019; 54:13993003.01647-2019. [DOI: 10.1183/13993003.01647-2019] [Citation(s) in RCA: 509] [Impact Index Per Article: 101.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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17
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Held M, Joa F, Wilkens H. [Pulmonary embolism]. MMW Fortschr Med 2018; 160:48-56. [PMID: 29582315 DOI: 10.1007/s15006-018-0010-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- Matthias Held
- Klinikum Würzburg Mitte, Standort Missioklinik, Innere Medizin, Pneumologie und Beatmungsmedizin, Onkologie und Umweltmedizin, Zentrum für pulmonale Hypertonie und Lungengefäßkrankheiten, Salvatorstraße 7, D-97074, Würzburg, Deutschland.
| | - Franziska Joa
- Zentrum für pulmonale Hypertonie und Lungengefäßkrankheiten, Würzburg, Deutschland
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Esposito R, Santoro C, Sorrentino R, Alcidi G, De Roberto AM, Santoro A, Tufano A, Trimarco B, Galderisi M. The role of cardiovascular ultrasound in diagnosis and management of pulmonary embolism. Future Cardiol 2017; 13:465-477. [PMID: 28832194 DOI: 10.2217/fca-2017-0037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
The diagnosis of acute pulmonary embolism (PE) is one of the most important problems in medical emergencies. Commonly accepted criterion for diagnosis of deep venous thrombosis is the lack of vein compressibility assessed by Compression UltraSonography. Echocardiography represents an easily available and reliable imaging technique in the clinical setting of hemodynamic instability and in the direct visualization of thromboembolic masses in the right heart chambers. Moreover, echocardiography is useful for prognostic stratification after acute PE as right ventricular dysfunction is the most important predictor of mortality in this context. This review aims to highlight usefulness, potentialities and perspectives of standard and advanced echocardiography in evaluating patients affected by PE.
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Affiliation(s)
- Roberta Esposito
- Department of Advanced Biomedical Sciences, Federico II University Hospital, Naples, Italy
| | - Ciro Santoro
- Department of Advanced Biomedical Sciences, Federico II University Hospital, Naples, Italy
| | - Regina Sorrentino
- Department of Advanced Biomedical Sciences, Federico II University Hospital, Naples, Italy
| | - Gianmarco Alcidi
- Department of Clinical Medicine & Surgery, Federico II University Hospital, Naples, Italy
| | - Anna Maria De Roberto
- Department of Advanced Biomedical Sciences, Federico II University Hospital, Naples, Italy
| | | | - Antonella Tufano
- Department of Clinical Medicine & Surgery, Federico II University Hospital, Naples, Italy
| | - Bruno Trimarco
- Department of Advanced Biomedical Sciences, Federico II University Hospital, Naples, Italy
| | - Maurizio Galderisi
- Department of Advanced Biomedical Sciences, Federico II University Hospital, Naples, Italy
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Armstrong L, Gleeson F, Mackillop L, Mutch S, Beale A. Survey of UK imaging practice for the investigation of pulmonary embolism in pregnancy. Clin Radiol 2017; 72:696-701. [DOI: 10.1016/j.crad.2017.03.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 03/13/2017] [Accepted: 03/30/2017] [Indexed: 01/26/2023]
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Carrillo Alcaraz A, Martínez AL, Solano FS. Diagnóstico de la embolia pulmonar. El punto de vista del médico clínico. RADIOLOGIA 2017; 59:166-176. [DOI: 10.1016/j.rx.2016.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 10/02/2016] [Accepted: 10/14/2016] [Indexed: 12/27/2022]
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21
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Tilve-Gómez A, Rodríguez-Fernández P, Trillo-Fandiño L, Plasencia-Martínez JM. Imaging techniques used in the diagnostic workup of acute venous thromboembolic disease. RADIOLOGIA 2016; 59:329-342. [PMID: 27986265 DOI: 10.1016/j.rx.2016.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 09/09/2016] [Accepted: 10/24/2016] [Indexed: 10/20/2022]
Abstract
Early diagnosis is one of the most important factors affecting the prognosis of pulmonary embolism (PE); however, the clinical presentation of PE is often very unspecific and it can simulate other diseases. For these reasons, imaging tests, especially computed tomography angiography (CTA) of the pulmonary arteries, have become the keystone in the diagnostic workup of PE. The wide availability and high diagnostic performance of pulmonary CTA has led to an increase in the number of examinations done and a consequent increase in the population's exposure to radiation and iodinated contrast material. Thus, other techniques such as scintigraphy and venous ultrasonography of the lower limbs, although less accurate, continue to be used in certain circumstances, and optimized protocols have been developed for CTA to reduce the dose of radiation (by decreasing the kilovoltage) and the dose of contrast agents. We describe the technical characteristics and interpretation of the findings for each imaging technique used to diagnose PE and discuss their advantages and limitations; this knowledge will help the best technique to be chosen for each case. Finally, we comment on some data about the increased use of CTA, its clinical repercussions, its "overuse", and doubts about its cost-effectiveness.
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Affiliation(s)
- A Tilve-Gómez
- Servicio de Radiodiagnóstico, IISGS, XXIV, Hospital Álvaro Cunqueiro, Vigo (Pontevedra), España.
| | - P Rodríguez-Fernández
- Servicio de Radiodiagnóstico, IISGS, XXIV, Hospital Álvaro Cunqueiro, Vigo (Pontevedra), España
| | - L Trillo-Fandiño
- Servicio de Radiodiagnóstico, IISGS, XXIV, Hospital Álvaro Cunqueiro, Vigo (Pontevedra), España
| | - J M Plasencia-Martínez
- Servicio de Radiodiagnóstico, Hospital General Universitario José María Morales Meseguer, Murcia, España
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Voukalis C, Lip GYH, Shantsila E. Non-vitamin K oral anticoagulants versus vitamin K antagonists in the treatment of venous thromboembolic disease. Expert Opin Pharmacother 2016; 17:2033-47. [DOI: 10.1080/14656566.2016.1232393] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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23
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Watanabe N, Fettich J, Küçük NÖ, Kraft O, Mut F, Choudhury P, Sharma SK, Endo K, Dondi M. Modified PISAPED Criteria in Combination with Ventilation Scintigraphic Finding for Predicting Acute Pulmonary Embolism. World J Nucl Med 2015; 14:178-83. [PMID: 26420988 PMCID: PMC4564920 DOI: 10.4103/1450-1147.163248] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
This prospective clinical study aimed at assessing three pulmonary scintigraphic algorithms to detect acute pulmonary embolism (PE): Lung ventilation/perfusion (V/Q) scintigraphy along with modified prospective investigation of pulmonary embolism diagnosis (PIOPED) criteria; lung perfusion scintigraphy along with prospective investigative study of acute pulmonary embolism diagnosis (PISAPED) criteria; and lung perfusion scan in combination with ventilation scan, along with modified PISAPED criteria, which were newly developed. Patients with suspicion of PE were eligible for this study if they had no abnormal chest x-ray. Their diagnostic workup included a clinical assessment, a pulmonary V/Q scintigraphy, and CT pulmonary angiography (CTPA), as well as a clinical outcome assessment over a period of 24 weeks. Referred to the final clinical diagnosis of patients, the sensitivity and specificity of each algorithm were evaluated. The diagnostic performance of each algorithm by the area under the maximum likelihood fitted receiver operating characteristic (ROC) curve was determined. With respect to the PISAPED criteria, the sensitivity was 60.8% and specificity was 87.3%. No patient was classified into nondiagnostic category. The PIOPED criteria showed that the sensitivity was 95.0% and specificity was 88.2%, while 57.4% of the patients were in nondiagnostic category. The areas under the ROC curve constructed from the PISAPED criteria results and the modified PIOPED criteria results were 0.734 and 0.859 (P < 0.01), respectively. The modified PISAPED criteria demonstrated that the sensitivity was 83.8% and specificity was 89.1%. No patient was classified into nondiagnostic category. The area under the ROC curve constructed from modified PISAPED criteria was 0.864 (P < 0.01). Perfusion scans used with ventilation scans and modified PISAPED criteria may increase the diagnostic accuracy of pulmonary scintigraphy for acute PE, compared with the two major algorithms.
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Affiliation(s)
- Naoyuki Watanabe
- Department of Nuclear Sciences and Applications, Division of Human Health, International Atomic Energy Agency, Vienna, Austria
| | - Jure Fettich
- Department of Nuclear Medicine, University Medical Center, Ljubljana, Slovenia
| | | | - Otakar Kraft
- Department of Nuclear Medicine, University Hospital, University of Strava, Ostrava, Czech Republic
| | - Fernando Mut
- Nuclear Medicine Service, Spanish Association Hospital, Montevideo, Uruguay
| | - Partha Choudhury
- Department of Nuclear Medicine, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
| | - Surendra K. Sharma
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Keigo Endo
- Kyoto Medical Science College, Kyoto, Japan
| | - Maurizio Dondi
- Department of Nuclear Sciences and Applications, Division of Human Health, International Atomic Energy Agency, Vienna, Austria
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Ma Y, Yan S, Zhou L, Yuan DT. Competitive assessments of pulmonary embolism: Noninvasiveness versus the golden standard. Vascular 2015; 24:217-24. [PMID: 26038123 DOI: 10.1177/1708538115589893] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Diagnosis of suspected pulmonary embolism (PE) is crucial as undiagnosed and over-diagnosis can both lead to serious consequences. Contemporary diagnostic approach of PE is a sequential combination assessment beginning with clinical assessment, validated with D-dimer measurement and confirmed with pulmonary angiography or imaging. Since the invasive pulmonary angiography is risky and costly, imaging is a warranted tool in the diagnosis procedure. CT pulmonary angiography is a less-invasive method with general availability, studies provide favorable evidences for CT pulmonary angiography as a stand-alone test for excluding PE, and it has become the first choice of tests in emergency department for suspected PE in most centers. Ventilation/perfusion single-photon emission CT signifies a new era in nuclear medicine. It has excellent sensitivity and specificity, fast procedure, low radiation exposure, few complications and contradictions. Besides, MR angiography is another possible and promising approach for diagnosis of suspected PE with much safer contrast agents than CT and no ionizing radiation. With wide availability and less invasive effects, imaging becomes a firsthand tool to obtain optimal accuracy in the diagnosis work up in clinic nowadays. This review summarizes the current methods in diagnosing PE and the update of imaging assessments of the disease.
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Affiliation(s)
- Yuxia Ma
- Division of Internal Medicine, Cangzhou Central Hospital, Cangzhou,China
| | - Shi Yan
- Department of Emergency, The Affiliated Huai'an Hospital of Xuzhou Medical College and The Second People's Hospital of Huai'an, Huai'an, China
| | - Lin Zhou
- Department of Cardiology, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Dong-Tang Yuan
- Department of Orthopedics, Huai'an First People's Hospital, Nanjing Medical University, Huai'an, China
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Konstantinides SV, Torbicki A, Agnelli G, Danchin N, Fitzmaurice D, Galiè N, Gibbs JSR, Huisman MV, Humbert M, Kucher N, Lang I, Lankeit M, Lekakis J, Maack C, Mayer E, Meneveau N, Perrier A, Pruszczyk P, Rasmussen LH, Schindler TH, Svitil P, Vonk Noordegraaf A, Zamorano JL, Zompatori M. 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J 2014; 35:3033-69, 3069a-3069k. [PMID: 25173341 DOI: 10.1093/eurheartj/ehu283] [Citation(s) in RCA: 1836] [Impact Index Per Article: 183.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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26
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Lung tissue density measured by low-dose CT during pulmonary perfusion SPECT/CT as a tool for differentiation pulmonary embolism from chronic obstructive pulmonary disease - A pilot study. COR ET VASA 2013. [DOI: 10.1016/j.crvasa.2013.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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27
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Mortensen J, Gutte H. SPECT/CT and pulmonary embolism. Eur J Nucl Med Mol Imaging 2013; 41 Suppl 1:S81-90. [PMID: 24213621 PMCID: PMC4003400 DOI: 10.1007/s00259-013-2614-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Accepted: 10/10/2013] [Indexed: 11/04/2022]
Abstract
Acute pulmonary embolism (PE) is diagnosed either by ventilation/perfusion (V/P) scintigraphy or pulmonary CT angiography (CTPA). In recent years both techniques have improved. Many nuclear medicine centres have adopted the single photon emission CT (SPECT) technique as opposed to the planar technique for diagnosing PE. SPECT has been shown to have fewer indeterminate results and a higher diagnostic value. The latest improvement is the combination of a low-dose CT scan with a V/P SPECT scan in a hybrid tomograph. In a study comparing CTPA, planar scintigraphy and SPECT alone, SPECT/CT had the best diagnostic accuracy for PE. In addition, recent developments in the CTPA technique have made it possible to image the pulmonary arteries of the lungs in one breath-hold. This development is based on the change from a single-detector to multidetector CT technology with an increase in volume coverage per rotation and faster rotation. Furthermore, the dual energy CT technique is a promising modality that can provide functional imaging in combination with anatomical information. Newer high-end CT scanners and SPECT systems are able to visualize smaller subsegmental emboli. However, consensus is lacking regarding the clinical impact and treatment. In the present review, SPECT and SPECT in combination with low-dose CT, CTPA and dual energy CT are discussed in the context of diagnosing PE.
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Affiliation(s)
- Jann Mortensen
- Department of Clinical Physiology, Nuclear Medicine & PET, Rigshospitalet, Copenhagen University Hospital, 2100, Copenhagen, Denmark,
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Dondi M. Guest editorial: IAEA approach to meet nuclear medicine needs of the emerging world. Semin Nucl Med 2013; 43:159-60. [PMID: 23561451 DOI: 10.1053/j.semnuclmed.2012.11.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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29
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Perfusion SPECT in patients with suspected pulmonary embolism: how much sensitivity is needed to keep patients alive? Eur J Nucl Med Mol Imaging 2013; 40:1428-31. [PMID: 23748237 DOI: 10.1007/s00259-013-2470-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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30
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SOLER XAVIER, KERR KIMM, MARSH JAMESJ, RENNER JOHNW, HOH CARLK, TEST VICTORJ, MORRIS TIMOTHYA. Pilot study comparing SPECT perfusion scintigraphy with CT pulmonary angiography in chronic thromboembolic pulmonary hypertension. Respirology 2011; 17:180-4. [DOI: 10.1111/j.1440-1843.2011.02061.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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31
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Positron emission and single-photon emission imaging: synergy rather than competition. Eur J Nucl Med Mol Imaging 2011; 38:1189-90. [PMID: 21400010 DOI: 10.1007/s00259-011-1767-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Marshall PS, Mathews KS, Siegel MD. Diagnosis and management of life-threatening pulmonary embolism. J Intensive Care Med 2011; 26:275-94. [PMID: 21606060 DOI: 10.1177/0885066610392658] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2009] [Accepted: 04/22/2010] [Indexed: 01/01/2023]
Abstract
Pulmonary embolus (PE) is estimated to cause 200 000 to 300 000 deaths annually. Many deaths occur in hemodynamically unstable patients and the estimated mortality for inpatients with hemodynamic instability is between 15% and 25%. The diagnosis of PE in the critically ill is often challenging because the presentation is nonspecific. Computed tomographic pulmonary angiography appears to be the most useful study for diagnosis of PE in the critically ill. For patients with renal insufficiency and contrast allergy, the ventilation perfusion scan provides an alternative. For patients too unstable to travel, echocardiography (especially transesophageal echocardiography) is another option. A positive result on lower extremity Doppler ultrasound can also aid in the decision to treat. The choice of treatment in PE depends on the estimated risk of poor outcome. The presence of hypotension is the most significant predictor of poor outcome and defines those with massive PE. Normotensive patients with evidence of right ventricular (RV) dysfunction, as assessed by echocardiography, comprise the sub-massive category and are at intermediate risk of poor outcomes. Clinically, those with sub-massive PE are difficult to distinguish from those with low-risk PE. Cardiac troponin, brain natriuretic peptide, and computed tomographic pulmonary angiography can raise the suspicion that a patient has sub-massive PE, but the echocardiogram remains the primary means of identifying RV dysfunction. The initial therapy for patients with PE is anticoagulation. Use of vasopressors, inotropes, pulmonary artery (PA) vasodilators and mechanical ventilation can stabilize critically ill patients. The recommended definitive treatment for patients with massive PE is thrombolysis (in addition to anticoagulation). In massive PE, thrombolytics reduce the risk of recurrent PE, cause rapid improvement in hemodynamics, and probably reduce mortality compared with anticoagulation alone. For patients with a contraindication to anticoagulation and thrombolytic therapy, surgical embolectomy and catheter-based therapies are options. Thrombolytic therapy in sub-massive PE results in improved pulmonary perfusion, reduced PA pressures, and a less complicated hospital course. No survival benefit has been documented, however. If one is considering the use of thrombolytic therapy in sub-massive PE, the limited documented benefit must be weighed against the increased risk of life-threatening hemorrhage. The role of surgical embolectomy and catheter-based therapies in this population is unclear. Evidence suggests that sub-massive PE is a heterogeneous group with respect to risk. It is possible that those at highest risk may benefit from thrombolysis, but existing studies do not identify subgroups within the sub-massive category. The role of inferior vena cava (IVC) filters, catheter-based interventions, and surgical embolectomy in life-threatening PE has yet to be completely defined.
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Affiliation(s)
- Peter S Marshall
- Pulmonary & Critical Care Section, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA.
| | - Kusum S Mathews
- Pulmonary & Critical Care Section, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Mark D Siegel
- Pulmonary & Critical Care Section, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
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Yang GF, Yang X, Zhang LJ, Zhu H, Chai X, Hu XB, Hu YX, Lu GM. Pulmonary enhancement imaging with dual energy CT for the detection of pulmonary embolism in a rabbit model: comparison to perfusion planar scintigraphy, SPECT and SPECT-CT modalities. Acad Radiol 2011; 18:605-14. [PMID: 21474059 DOI: 10.1016/j.acra.2010.12.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2010] [Revised: 11/29/2010] [Accepted: 12/11/2010] [Indexed: 10/18/2022]
Abstract
RATIONALE AND OBJECTIVES Pulmonary enhancement imaging (PEI) derived from dual-energy computed tomographic (CT) imaging has been used to detect perfusion defects from pulmonary embolism (PE). The purpose of this study was to compare the ability of PEI, planar, single photon-emission CT (SPECT) perfusion scintigraphy, and SPECT-CT fusion images to detect perfusion defect in a PE rabbit model. MATERIALS AND METHODS A PE model was made by injecting Gelfoam into the femoral veins of rabbits (n = 16). After 2 hours, 16 experimental rabbits and three control rabbits underwent contrast-enhanced dual-energy CT scans, from which PEI and CT pulmonary angiography were created, and planar, SPECT, and SPECT-CT fusion images were then obtained and evaluated. Pathologic determination of locations and numbers of lung lobes with PE were recorded. The sensitivity and specificity of the above-mentioned modalities were calculated using the histopathologic results as reference standards. RESULTS Emboli were present in 31 pulmonary lobes and absent in 64 lung lobes in histopathologic analysis. With the histopathologic findings as the gold standard, sensitivities and specificities of PEI, planar, SPECT, and SPECT-CT fusion images to detect PE were 100% and 96.9%, 71.0% and 84.4%, 77.4% and 90.6%, and 74.2% and 93.8%, respectively. McNemar's tests showed that PEI had higher diagnostic accuracy for the detection of PE than three scintigraphic images (all P values < .05), while three scintigraphic images had similar diagnostic accuracy (all P values = NS). CONCLUSIONS This study demonstrates that PEI from dual-energy CT imaging can provide higher diagnostic accuracy for detecting PE than planar, SPECT, and SPECT-CT fusion images in a rabbit model.
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Stein PD, Sostman HD, Dalen JE, Bailey DL, Bajc M, Goldhaber SZ, Goodman LR, Gottschalk A, Hull RD, Matta F, Pistolesi M, Tapson VF, Weg JG, Wells PS, Woodard PK. Controversies in Diagnosis of Pulmonary Embolism. Clin Appl Thromb Hemost 2010; 17:140-9. [DOI: 10.1177/1076029610389027] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The approach to the diagnosis of acute pulmonary embolism (PE) is under constant revision with advances in technology, noninvasive approaches, and increasing awareness of the risks of ionizing radiation. Optimal approaches in some categories of patients are controversial. Data are insufficient for evidence-based recommendations. Therefore, this survey of investigators in the field was undertaken. Even among experts there were marked differences of opinion regarding the approach to the diagnosis of acute PE. Although CT pulmonary angiography was usually the imaging test of choice, the respondents were keenly aware of the dangers of ionizing radiation. In view of advances in scintigraphic diagnosis since the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) trial, ventilation/perfusion (V/Q) lung scans or perfusion scans alone and single photon emission computed tomography (SPECT) V/Q lung scans are often recommended. The choice depends on the patient’s age, gender, and complexity of the findings on the plain chest radiograph.
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Affiliation(s)
- Paul D. Stein
- Department of Internal Medicine and Research and Advanced Studies Program, Michigan State University College of Osteopathic Medicine, East Lansing, MI, USA, Dept of Research, St. Mary Mercy Hospital, Livonia, MI, USA,
| | - H. Dirk Sostman
- Office of the Dean, Weill Cornell Medical College and Methodist Hospital, Houston, TX, USA
| | - James E. Dalen
- College of Medicine, University of Arizona, Tucson, AZ, USA
| | - Dale L. Bailey
- Department of Nuclear Medicine, University of Sydney, Australia
| | - Marika Bajc
- Department of Clinical Physiology, Lund University Hospital, Lund, Sweden
| | - Samuel Z. Goldhaber
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | - Russell D. Hull
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Fadi Matta
- Department of Internal Medicine and Research and Advanced Studies Program, Michigan State University College of Osteopathic Medicine, East Lansing, MI, USA
| | - Massimo Pistolesi
- Department of Internal Medicine, University of Florence, Florence, Italy
| | | | - John G. Weg
- Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Philip S. Wells
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Canada
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Niemann T, Nicolas G, Roser HW, Müller-Brand J, Bongartz G. Imaging for suspected pulmonary embolism in pregnancy-what about the fetal dose? A comprehensive review of the literature. Insights Imaging 2010; 1:361-372. [PMID: 22347929 PMCID: PMC3259315 DOI: 10.1007/s13244-010-0043-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2010] [Revised: 08/13/2010] [Accepted: 09/15/2010] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVE: To give a comprehensive overview of fetal doses reported in the literature when imaging the pregnant woman with suspected pulmonary embolism (PE). METHODS: A comprehensive literature search in the PubMed, MEDLINE and EMBASE databases yielded a total of 1,687 papers that were included in the analysis and have been analysed with regard to fetal dose in suspected PE radiological imaging strategies. RESULTS: Fetal dose in chest computed tomography (CT) ranges between 0.013 and 0.026 mGy in early and 0.06-0.1 mGy in late pregnancy compared with 99mTc-MAA perfusion scintigraphy with a fetal dose of 0.1-0.6 mGy in early and 0.6-0.8 mGy in late pregnancy. (99m)Tc-aerosol ventilation scintigraphy results in 0.1-0.3 mGy. However, there is concern about female breast irradiation in CT, which is higher than in scintigraphy. CT radiation risks for breast tissue remain unclear. CONCLUSION: Knowledge of dosimetry and radiation risks is crucial in the radiological work-up of suspected PE in pregnancy. It is reasonable to reserve scintigraphy for pregnant patients with normal chest radiography findings and no history of asthma or chronic lung disease. Performing CT applying dose reduction instead of scintigraphy will minimise fetal radiation dose and maximise the diagnostic value.
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Pistolesi M. Pulmonary CT angiography in patients suspected of having pulmonary embolism: case finding or screening procedure? Radiology 2010; 256:334-7. [PMID: 20656827 DOI: 10.1148/radiol.10100662] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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A review on the clinical uses of SPECT/CT. Eur J Nucl Med Mol Imaging 2010; 37:1959-85. [PMID: 20182712 DOI: 10.1007/s00259-010-1390-8] [Citation(s) in RCA: 205] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2009] [Accepted: 01/11/2010] [Indexed: 01/02/2023]
Abstract
In the era when positron emission tomography (PET) seems to constitute the most advanced application of nuclear medicine imaging, still the conventional procedure of single photon emission computed tomography (SPECT) is far from being obsolete, especially if combined with computed tomography (CT). In fact, this dual modality imaging technique (SPECT/CT) lends itself to a wide variety of useful diagnostic applications whose clinical impact is in most instances already well established, while the evidence is growing for newer applications. The increasing availability of new hybrid SPECT/CT devices with advanced technology offers the opportunity to shorten acquisition time and to provide accurate attenuation correction and fusion imaging. In this review we analyse and discuss the capabilities of SPECT/CT for improving sensitivity and specificity in the imaging of both oncological and non-oncological diseases. The main advantages of SPECT/CT are represented by better attenuation correction, increased specificity, and accurate depiction of the localization of disease and of possible involvement of adjacent tissues. Endocrine and neuroendocrine tumours are accurately localized and characterized by SPECT/CT, as also are solitary pulmonary nodules and lung cancers, brain tumours, lymphoma, prostate cancer, malignant and benign bone lesions, and infection. Furthermore, hybrid SPECT/CT imaging is especially suited to support the increasing applications of minimally invasive surgery, as well as to precisely define the diagnostic and prognostic profile of cardiovascular patients. Finally, the applications of SPECT/CT to other clinical disorders or malignant tumours is currently under extensive investigation, with encouraging results in terms of diagnostic accuracy.
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40
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Stein PD, Freeman LM, Sostman HD, Goodman LR, Woodard PK, Naidich DP, Gottschalk A, Bailey DL, Matta F, Yaekoub AY, Hales CA, Hull RD, Leeper KV, Tapson VF, Weg JG. SPECT in Acute Pulmonary Embolism. J Nucl Med 2009; 50:1999-2007. [DOI: 10.2967/jnumed.109.063958] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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41
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Diagnosing pulmonary embolism: clinical problem or methodological issue? Eur J Nucl Med Mol Imaging 2009; 36:522-8. [PMID: 19137291 DOI: 10.1007/s00259-008-1059-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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42
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Bajc M, Jonson B. Ventilation/perfusion SPECT — an essential but underrated method for diagnosis of pulmonary embolism and other diseases. Eur J Nucl Med Mol Imaging 2009; 36:875-8. [DOI: 10.1007/s00259-009-1125-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2009] [Accepted: 03/13/2009] [Indexed: 11/28/2022]
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43
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Freeman LM, Haramati LB. V/Q scintigraphy: alive, well and equal to the challenge of CT angiography. Eur J Nucl Med Mol Imaging 2009; 36:499-504. [DOI: 10.1007/s00259-009-1068-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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