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Vinson DR, Roubinian NH, Pai AP, Sperling JD. Expanding outpatient management of low-risk pulmonary embolism to the pregnant population: a case series. Eur Heart J Case Rep 2024; 8:ytae441. [PMID: 39308925 PMCID: PMC11416013 DOI: 10.1093/ehjcr/ytae441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 03/16/2024] [Accepted: 08/19/2024] [Indexed: 09/25/2024]
Abstract
Background Outpatient treatment of pregnant patients with acute pulmonary embolism (PE) is recommended by some obstetric and haematology societies but has not been described in the literature. Little is known about patient selection and clinical outcomes. Case summary We report two cases of pregnant patients diagnosed with acute PE. The first, at 9 weeks of gestational age, presented to the emergency department with 12 h of pleuritic chest pain and was diagnosed with segmental PE. She was normotensive and tachycardic without evidence of right ventricular dysfunction. She received multispecialty evaluation, was deemed suitable for outpatient management, and, after 12 h of monitoring, was discharged home on enoxaparin with close follow-up. The second case, at 30 weeks of gestational age, presented to obstetrics clinic with 3 days of dyspnoea. Vital signs were normal except for tachycardia. She was referred to labour and delivery, where she was diagnosed with segmental PE. Her vital signs were stable, and she had no evidence of right ventricular dysfunction. After 6 h of monitoring, she was discharged home on enoxaparin with close follow-up. Neither patient developed antenatal complications from their PE or its treatment. Discussion This case series is the first to our knowledge to describe patient and treatment characteristics of pregnant patients with acute PE cared for as outpatients. We propose a definition for this phenomenon and discuss the benefits of and provisional selection criteria for outpatient PE management, while engaging with professional society guidelines and the literature. This understudied practice warrants further research.
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Affiliation(s)
- David R Vinson
- The Permanente Medical Group, 1800 Harrison St., Oakland, CA 94612, USA
- Kaiser Permanente Northern California Division of Research, 4480 Hacienda Dr., Pleasanton, CA 94588, USA
- Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, 1600 Eureka Road, Roseville, CA 95661, USA
| | - Nareg H Roubinian
- The Permanente Medical Group, 1800 Harrison St., Oakland, CA 94612, USA
- Kaiser Permanente Northern California Division of Research, 4480 Hacienda Dr., Pleasanton, CA 94588, USA
- Department of Pulmonary and Critical Care Medicine, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
| | - Ashok P Pai
- The Permanente Medical Group, 1800 Harrison St., Oakland, CA 94612, USA
- Kaiser Permanente Northern California Division of Research, 4480 Hacienda Dr., Pleasanton, CA 94588, USA
- Department of Hematology and Oncology, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
| | - Jeffrey D Sperling
- The Permanente Medical Group, 1800 Harrison St., Oakland, CA 94612, USA
- Department of Maternal-Fetal Medicine, Kaiser Permanente Modesto Medical Center, Modesto, CA, USA
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Casey SD, Zekar L, Somers MJ, Westafer LM, Reed ME, Vinson DR. Bilateral Emboli and Highest Heart Rate Predict Hospitalization of Emergency Department Patients With Acute, Low-Risk Pulmonary Embolism. Ann Emerg Med 2023; 82:369-380. [PMID: 37028997 PMCID: PMC11126867 DOI: 10.1016/j.annemergmed.2023.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 02/14/2023] [Accepted: 02/16/2023] [Indexed: 04/09/2023]
Abstract
STUDY OBJECTIVE Some patients with acute pulmonary embolism (PE) will suffer adverse clinical outcomes despite being low risk by clinical decision rules. Emergency physician decisionmaking processes regarding which low-risk patients require hospitalization are unclear. Higher heart rate (HR) or embolic burden may increase short-term mortality risk, and we hypothesized that these variables would be associated with an increased likelihood of hospitalization for patients designated as low risk by the PE Severity Index. METHODS This was a retrospective cohort study of 461 adult emergency department (ED) patients with a PE Severity Index score of fewer than 86 points. Primary exposures were the highest observed ED HR, most proximal embolus location (proximal vs distal), and embolism laterality (bilateral vs unilateral PE). The primary outcome was hospitalization. RESULTS Of 461 patients meeting inclusion criteria, most (57.5%) were hospitalized, 2 patients (0.4%) died within 30 days, and 142 (30.8%) patients were at elevated risk by other criteria (Hestia criteria or biochemical/radiographic right ventricular dysfunction). Variablesassociated with an increased likelihood of admission were highest observed ED HR of ≥110 beats/minute (vs HR <90 beats/min) (adjusted odds ratio [aOR] 3.11; 95% confidence interval [CI] 1.07 to 9.57), highest ED HR 90 to 109 (aOR 2.03; 95% CI 1.18-3.50) and bilateral PE (aOR 1.92; 95% CI 1.13 to 3.27). Proximal embolus location was not associated with the likelihood of hospitalization (aOR 1.19; 95% CI 0.71 to 2.00). CONCLUSIONS Most patients were hospitalized, often with recognizable high-risk characteristics not accounted for by the PE Severity Index. Highest ED HR of ≥90 beats/min and bilateral PE were associated with a physician's decision for hospitalization.
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Affiliation(s)
- Scott D Casey
- Permanente Medical Group, Oakland, CA; Kaiser Permanente Division of Research, Oakland, CA; Kaiser Permanente CREST Network.
| | - Lara Zekar
- Department of Emergency Medicine, University of California, Davis, CA
| | - Madeline J Somers
- Kaiser Permanente Division of Research, Oakland, CA; Kaiser Permanente CREST Network
| | - Lauren M Westafer
- Department of Emergency Medicine, UMASS Chan Medical School-Baystate, Springfield, MA
| | - Mary E Reed
- Kaiser Permanente Division of Research, Oakland, CA; Kaiser Permanente CREST Network
| | - David R Vinson
- Permanente Medical Group, Oakland, CA; Kaiser Permanente Division of Research, Oakland, CA; Kaiser Permanente CREST Network; Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, Roseville, CA
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Adda-Rezig I, Cossu J, Falvo N, Ecarnot F, Desmettre T, Meneveau N, Piazza G, Chopard R. Home treatment versus early discharge for the outpatient management of acute pulmonary embolism: A non-interventional, post-hoc cohort analysis. Thromb Res 2023; 227:25-33. [PMID: 37209588 DOI: 10.1016/j.thromres.2023.05.013] [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: 10/04/2022] [Revised: 03/06/2023] [Accepted: 05/08/2023] [Indexed: 05/22/2023]
Abstract
INTRODUCTION We prospectively investigated whether home treatment of pulmonary embolism (PE), is as effective and safe as the recommended early discharge management in terms of outcomes at 3 months. METHODS We performed a post hoc analysis of prospectively and consecutively recorded data in acute PE patients from a tertiary care facility between January 2012 and November 2021. Home treatment was defined as discharge to home directly from the emergency department (ED) after <24 h stay. Early discharge was defined as in-hospital stay of ≥24 h and ≤48 h. Primary efficacy and safety outcomes were a composite of PE-related death or recurrent venous thrombo-embolism, and major bleeding, respectively. Outcomes between groups were compared using penalized multivariable models. RESULTS In total, 181 patients (30.6 %) were included in the home treatment group and 463 (69.4 %) patients in the early discharge group. Median duration of ED stay was 8.1 h (IQR, 3.6-10.2 h) in the home treatment group, and median length of hospital stay was 36.4 h (IQR, 28.7-40.2) in the early discharge group. The adjusted rate of the primary efficacy outcome was 1.90 % (95 % CI, 0.16-15.2) vs 2.05 % (95 % CI, 0.24-10.1) for home treatment vs early discharge (hazard ratio (HR) 0.86 (95 % CI, 0.27-2.74). The adjusted rates of the primary safety outcome did not differ between groups at 3 months. CONCLUSIONS In a non-randomized cohort of selected acute PE patients, home treatment provided comparable rates of adverse VTE and bleeding events to the recommended early discharge management, and appears to have similar clinical outcomes at 3 months.
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Affiliation(s)
| | - Johann Cossu
- Emergency Department, University Hospital Jean Minjoz, Besançon, France
| | - Nicolas Falvo
- Department of Internal Medicine, University Hospital Dijon-Bourgogne, Dijon, France
| | - Fiona Ecarnot
- Department of Cardiology, University Hospital Jean Minjoz, Besançon, France; EA3920, University of Franche-Comté, Besançon, France
| | - Thibaut Desmettre
- Emergency Department, University Hospital Jean Minjoz, Besançon, France
| | - Nicolas Meneveau
- Department of Cardiology, University Hospital Jean Minjoz, Besançon, France; EA3920, University of Franche-Comté, Besançon, France; F-CRIN, INNOVTE Network, France
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Romain Chopard
- Department of Cardiology, University Hospital Jean Minjoz, Besançon, France; EA3920, University of Franche-Comté, Besançon, France; F-CRIN, INNOVTE Network, France.
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Seedat ZO, Khan AU, Plisco MS. Pulmonary Embolism. N Engl J Med 2022; 387:1243. [PMID: 36170512 DOI: 10.1056/nejmc2210390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Tang Z, Fan K, Qiu L, Chen L, Qian Q, Zhang T, Wang Y, Han M, Deng C, He W. Clinical value and feasibility of CT pulmonary angiography with personalized injection of contrast agent in pulmonary embolism. Am J Transl Res 2022; 14:6774-6781. [PMID: 36247283 PMCID: PMC9556491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 05/19/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To determine the clinical value and feasibility of CT pulmonary angiography (CTPA) with personalized injection of contrast agent in pulmonary embolism (PE). METHODS In the present retrospective study, 130 patients who underwent CTPA examination in our hospital from June 2019 to May 2020 were evaluated. Among them, 67 cases were detected by CTPA with personalized injection of contrast agent as the observation group (Obs group), and 63 cases were detected by CTPA with bolus-tracking (BT) as the control group (Con group). The specificity, sensitivity and accuracy of the detection in the two groups were compared. The image quality score and superior vena cava artifact score of the two diagnostic methods were compared. Additionally, the volumetric CT dose index (CTDIvol) and dose length product (DLP) of the two groups were compared. RESULTS The Obs group yielded a significantly higher specificity in diagnosing PE than the Con group (P<0.05), but there were no significant differences between the two groups in the sensitivity and accuracy (P>0.05). The image quality score and superior vena cava artifact score of the two groups were not significantly different (P>0.05), and the Obs group showed significantly lower CTDIvol and DLP than the Con group (P<0.05). CONCLUSION CTPA with personalized injection of contrast agent has good diagnostic value for PE, with good imaging effect and safe profile, and has a lower radiation dose requirement.
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Affiliation(s)
- Zhiming Tang
- Department of Radiographic Imaging Center, The Second Affiliated Hospital, Hengyang Medical School, University of South ChinaNo. 35 Jiefang Avenue, Zhengxiang District, Hengyang 421000, Hunan Province, P. R. China
| | - Kun Fan
- Department of Radiographic Imaging Center, The Second Affiliated Hospital, Hengyang Medical School, University of South ChinaNo. 35 Jiefang Avenue, Zhengxiang District, Hengyang 421000, Hunan Province, P. R. China
| | - Lanyu Qiu
- Department of Radiographic Imaging Center, The Second Affiliated Hospital, Hengyang Medical School, University of South ChinaNo. 35 Jiefang Avenue, Zhengxiang District, Hengyang 421000, Hunan Province, P. R. China
| | - Likang Chen
- Department of General Practice, The Second Affiliated Hospital, Hengyang Medical School, University of South ChinaNo. 35 Jiefang Avenue, Zhengxiang District, Hengyang 421000, Hunan Province, P. R. China
| | - Qilin Qian
- Department of Radiographic Imaging Center, The Second Affiliated Hospital, Hengyang Medical School, University of South ChinaNo. 35 Jiefang Avenue, Zhengxiang District, Hengyang 421000, Hunan Province, P. R. China
| | - Ting Zhang
- Department of Radiographic Imaging Center, The Second Affiliated Hospital, Hengyang Medical School, University of South ChinaNo. 35 Jiefang Avenue, Zhengxiang District, Hengyang 421000, Hunan Province, P. R. China
| | - Yi Wang
- Department of Radiographic Imaging Center, The Second Affiliated Hospital, Hengyang Medical School, University of South ChinaNo. 35 Jiefang Avenue, Zhengxiang District, Hengyang 421000, Hunan Province, P. R. China
| | - Menglong Han
- Department of Radiographic Imaging Center, The Second Affiliated Hospital, Hengyang Medical School, University of South ChinaNo. 35 Jiefang Avenue, Zhengxiang District, Hengyang 421000, Hunan Province, P. R. China
| | - Chengjian Deng
- Department of Radiographic Imaging Center, The Second Affiliated Hospital, Hengyang Medical School, University of South ChinaNo. 35 Jiefang Avenue, Zhengxiang District, Hengyang 421000, Hunan Province, P. R. China
| | - Weihong He
- Department of Radiographic Imaging Center, The Second Affiliated Hospital, Hengyang Medical School, University of South ChinaNo. 35 Jiefang Avenue, Zhengxiang District, Hengyang 421000, Hunan Province, P. R. China
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Pagkratis N, Matsagas M, Malli F, Gourgoulianis KI, Kotsiou OS. Prevalence of Hemorrhagic Complications in Hospitalized Patients with Pulmonary Embolism. J Pers Med 2022; 12:jpm12071133. [PMID: 35887630 PMCID: PMC9320949 DOI: 10.3390/jpm12071133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 06/25/2022] [Accepted: 07/12/2022] [Indexed: 12/02/2022] Open
Abstract
Background: The prevalence of anticoagulant therapy-associated hemorrhagic complications in hospitalized patients with pulmonary embolism (PE) has been scarcely investigated. Aim: To evaluate the prevalence of hemorrhages in hospitalized PE patients. Methods: The Information System “ASKLIPIOS™ HOSPITAL” implemented in the Respiratory Medicine Department, University of Thessaly, was used to collect demographic, clinical and outcome data from January 2013 to April 2021. Results: 326 patients were included. Males outnumbered females. The population’s mean age was 68.7 ± 17.0 years. The majority received low molecular weight heparin (LMWH). Only 5% received direct oral anticoagulants. 15% of the population were complicated with hemorrhage, of whom 18.4% experienced a major event. Major hemorrhages were fewer than minor (29.8% vs. 70.2%, p = 0.001). Nadroparin related to 83.3% of the major events. Hematuria was the most common hemorrhagic event. 22% of patients with major events received a transfusion, and 11% were admitted to intensive care unit (ICU). The events lasted for 3 ± 2 days. No death was recorded. Conclusions: 1/5 of the patients hospitalized for PE complicated with hemorrhage without a fatal outcome. The hemorrhages were mainly minor and lasted for 3 ± 2 days. Among LMWHs, nadroparin was related to a higher percentage of hemorrhages.
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Affiliation(s)
| | - Miltiadis Matsagas
- Department of Respiratory Medicine, Faculty of Medicine, University of Thessaly, 41110 Larissa, Greece;
| | - Foteini Malli
- Vascular Surgery Department, Faculty of Medicine, University of Thessaly, 41110 Larissa, Greece;
| | | | - Ourania S. Kotsiou
- Vascular Surgery Department, Faculty of Medicine, University of Thessaly, 41110 Larissa, Greece;
- Correspondence:
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Vinson DR, Casey SD, Vuong PL, Huang J, Ballard DW, Reed ME. Sustainability of a Clinical Decision Support Intervention for Outpatient Care for Emergency Department Patients With Acute Pulmonary Embolism. JAMA Netw Open 2022; 5:e2212340. [PMID: 35576004 PMCID: PMC9112064 DOI: 10.1001/jamanetworkopen.2022.12340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
IMPORTANCE Physicians commonly hospitalize patients presenting to the emergency department (ED) with acute pulmonary embolism (PE), despite eligibility for safe outpatient management. Risk stratification using electronic health record-embedded clinical decision support systems can aid physician site-of-care decision-making and increase safe outpatient management. The long-term sustainability of early improvements after the cessation of trial-based, champion-led promotion is uncertain. OBJECTIVE To evaluate the sustainability of recommended site-of-care decision-making support 4 years after initial physician champion-led interventions to increase outpatient management for patients with acute PE. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study was conducted in 21 US community hospitals in an integrated health system. Participants included adult patients presenting to the ED with acute PE. Study sites had participated in an original decision-support intervention trial 4 years prior to the current study period: 10 sites were intervention sites, 11 sites were controls. In that trial, decision support with champion promotion resulted in significantly higher outpatient management at intervention sites compared with controls. After trial completion, all study sites were given continued access to a modified decision-support tool without further champion-led outreach. Data were analyzed from January 2019 to February 2020. EXPOSURES ED treatment with a modified clinical decision support tool. MAIN OUTCOMES AND MEASURES The main outcome was frequency of outpatient management, defined as discharge home directly from the ED, stratified by the PE Severity Index. The safety measure of outpatient care was 7-day PE-related hospitalization. RESULTS This study included 1039 patients, including 533 (51.3%) women, with a median (IQR) age of 65 (52-74) years. Nearly half (474 patients [45.6%]) were rated lower risk on the PE Severity Index. Overall, 278 patients (26.8%) were treated as outpatients, with only four 7-day PE-related hospitalizations (1.4%; 95% CI, 0.4%-3.6%). The practice gap in outpatient management created by the earlier trial persisted in the outpatient management for patients with lower risk: 109 of 236 patients (46.2%) at former intervention sites vs 81 of 238 patients (34.0%) at former control sites (difference, 12.2; [95% CI, 3.4-20.9] percentage points; P = .007), with wide interfacility variation (range, 7.1%-47.1%). CONCLUSIONS AND RELEVANCE In this cohort study, a champion-led, decision-support intervention to increase outpatient management for patients presenting to the ED with acute pulmonary embolism was associated with sustained higher rates of outpatient management 4 years later. The application of our findings to improving sustainability of practice change for other clinical conditions warrants further study.
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Affiliation(s)
- David R. Vinson
- The Permanente Medical Group, Oakland, California
- Kaiser Permanente Division of Research, Oakland, California
- The Kaiser Permanente CREST Network
- Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, Roseville, California
| | - Scott D. Casey
- The Kaiser Permanente CREST Network
- Department of Emergency Medicine, UC Davis Health, University of California, Davis, Sacramento
| | - Peter L. Vuong
- Department of Emergency Medicine, Kaiser Permanente Modesto Medical Center, Modesto, California
| | - Jie Huang
- Kaiser Permanente Division of Research, Oakland, California
- The Kaiser Permanente CREST Network
| | - Dustin W. Ballard
- The Permanente Medical Group, Oakland, California
- Kaiser Permanente Division of Research, Oakland, California
- The Kaiser Permanente CREST Network
- Department of Emergency Medicine, Kaiser Permanente San Rafael Medical Center, San Rafael, California
| | - Mary E. Reed
- Kaiser Permanente Division of Research, Oakland, California
- The Kaiser Permanente CREST Network
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Raper JD, Thomas AM, Lupez K, Cox CA, Esener D, Boyd JS, Nomura JT, Davison J, Ockerse PM, Leech S, Johnson J, Abrams E, Murphy K, Kelly C, O'Connell NS, Weekes AJ. Can right ventricular assessments improve triaging of low risk pulmonary embolism? Acad Emerg Med 2022; 29:835-850. [PMID: 35289978 DOI: 10.1111/acem.14484] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 01/21/2022] [Accepted: 02/21/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Identifying right ventricle (RV) abnormalities is important to stratifying pulmonary embolism (PE) severity. Disposition decisions are influenced by concerns about early deterioration. Triaging strategies, like the Simplified Pulmonary Embolism Severity Index (sPESI), do not include RV assessments as predictors or early deterioration as outcome(s). We aimed to (1) determine if RV assessment variables add prognostic accuracy for 5-day clinical deterioration in patients classified low risk by sPESI, and (2) determine the prognostic importance of RV assessments compared to other variables and to each other. METHODS We identified low risk sPESI patients (sPESI = 0) from a prospective PE registry. From a large field of candidate variables, we developed, and compared prognostic accuracy of, full and reduced random forest models (with and without RV assessment variables, respectively) on a validation database. We reported variable importance plots from full random forest and provided odds ratios for statistical inference of importance from multivariable logistic regression. Outcomes were death, cardiac arrest, hypotension, dysrhythmia, or respiratory failure within 5 days of PE. RESULTS Of 1736 patients, 610 (35.1%) were low risk by sPESI and 72 (11.8%) experienced early deterioration. Of the 610, RV abnormality was present in 157 (25.7%) by CT, 121 (19.8%) by echocardiography, 132 (21.6%) by natriuretic peptide, and 107 (17.5%) by troponin. For deterioration, the receiver operating characteristics for full and reduced random forest prognostic models were 0.80 (0.77-0.82) and 0.71 (0.68-0.73), respectively. RV assessments were the top four in the variable importance plot for the random forest model. Echocardiography and CT significantly increased predicted probability of 5-day clinical deterioration by the multivariable logistic regression. CONCLUSIONS A PE triaging strategy with RV imaging assessments had superior prognostic performance at classifying low risk for 5-day clinical deterioration versus one without.
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Affiliation(s)
- Jaron D. Raper
- Department of Emergency Medicine Atrium Health's Carolinas Medical Center Charlotte North Carolina USA
- Jaron D. RaperDepartment of Emergency Medicine University of Alabama at Birmingham Birmingham Alabama USA
| | - Alyssa M. Thomas
- Department of Emergency Medicine Atrium Health's Carolinas Medical Center Charlotte North Carolina USA
- Alyssa M. Thomas, Emergency Department Houston Methodist Baytown Hospital Houston Texas USA
| | - Kathryn Lupez
- Department of Emergency Medicine Atrium Health's Carolinas Medical Center Charlotte North Carolina USA
- Kathryn Lupez, Department of Emergency Medicine Tufts Medical Center Boston Massachusetts USA
| | - Carly A. Cox
- Department of Emergency Medicine Atrium Health's Carolinas Medical Center Charlotte North Carolina USA
- Carly A. Cox, Emergency Medicine of Idaho Meridian Idaho USA
| | - Dasia Esener
- Department of Emergency Medicine Kaiser Permanente San Diego California USA
| | - Jeremy S. Boyd
- Department of Emergency Medicine Vanderbilt University Medical Center Nashville Tennessee USA
| | - Jason T. Nomura
- Department of Emergency Medicine Christiana Care Newark Delaware USA
| | - Jillian Davison
- Department of Emergency Medicine Orlando Health Orlando Florida USA
| | - Patrick M. Ockerse
- Division of Emergency Medicine University of Utah Health Salt Lake City Utah USA
| | - Stephen Leech
- Department of Emergency Medicine Orlando Health Orlando Florida USA
| | - Jakea Johnson
- Department of Emergency Medicine Vanderbilt University Medical Center Nashville Tennessee USA
| | - Eric Abrams
- Department of Emergency Medicine Kaiser Permanente San Diego California USA
| | - Kathleen Murphy
- Department of Emergency Medicine Christiana Care Newark Delaware USA
| | - Christopher Kelly
- Division of Emergency Medicine University of Utah Health Salt Lake City Utah USA
| | - Nathaniel S. O'Connell
- Department of Biostatistics and Data Science Wake Forest School of Medicine Winston‐Salem North Carolina USA
| | - Anthony J. Weekes
- Department of Emergency Medicine Atrium Health's Carolinas Medical Center Charlotte North Carolina USA
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