Clinical characteristics of patients with acute pulmonary embolism: data from PIOPED II

Emergency Ultrasound Unveils Intermediate-High Risk Saddle Pulmonary Embolism with Extensive Bilateral Clot Burden, Masquerading as Micturition Syncope: A Case Report

BACKGROUND

Isolated syncope as the manifestation of pulmonary embolism (PE) is a rare and diagnostically challenging presentation that often leads to delayed or missed diagnosis, increasing morbidity and mortality. In spite of emphasizing cardiovascular etiologies of syncope, current guidelines offer essentially no guidance in establishing a diagnostic workup for PE in these patients. By performing bedside echocardiography, emergency physicians can accurately identify concerning features suggestive of PE in patients with syncope.

CASE REPORT

A 78-year-old man, receiving ertapenem via a peripherally inserted central catheter for treatment of extended spectrum β-lactamase urinary tract infection, presented to the emergency department for isolated syncope with collapse while urinating. Arriving asymptomatic with normal vital signs and a benign physical examination, a presumptive diagnosis of micturition syncope was made. However, subtle vital sign changes on reassessment prompted performance of a point-of-care echocardiogram, which revealed signs of right heart strain. A computed tomography angiogram confirmed a saddle PE with extensive bilateral clot burden. Catheter-directed thrombectomy was performed via interventional radiology, with successful removal of pulmonary emboli. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Pulmonary embolism presenting as isolated syncope represents a daunting diagnostic dilemma, as emergency physicians may not consider it, or anchor on more benign etiologies of syncope. Although lacking sufficient sensitivity to rule out PE, point-of-care echocardiography to evaluate for signs of right heart strain can quickly and effectively point toward the diagnosis, while also assessing for other emergent cardiovascular causes of syncope. Given the lack of evidence-based guidance concerning PE presenting as syncope, bedside echocardiography should be highly considered as a part of the emergency physician's diagnostic workup, especially in patients with abnormal vital signs.

Diagnostic Strategies in Pulmonary Embolism

Key to the diagnosis of pulmonary embolism (PE) is a careful bedside evaluation. After this, there are three further diagnostic steps. In all patients, estimation of the clinical probability of PE is performed. The other two steps are measurement of D-dimer when indicated and chest imaging when indicated. The clinical probability of PE is estimated at low, moderate, or high. The prevalence of PE is less than 15% among patients with low clinical probability, 15 to 40% with moderate clinical probability, and >40% in patients with high clinical probability. Clinical gestalt has been found to be very useful in estimating probability of PE. However, clinical prediction rules, such as Wells criteria, the modified Geneva score, and the PE rule out criteria have been advocated as adjuncts. In patients with high clinical probability, the high prevalence of PE can lower the D-dimer negative predictive value, which could increase the risk of diagnostic failure. Consequently, patients with high probability for PE need to proceed directly to chest imaging, without prior measurement of D-dimer level. Key studies in determining which low to moderate probability patients require chest imaging are the Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism (ADJUST-PE), the Simplified diagnostic management of suspected pulmonary embolism (YEARS), and the Pulmonary Embolism Graduated D-Dimer trials. In patients with low clinical probability, PE can be excluded without imaging studies if D-dimer is less than 1,000 ng/mL. In patients in whom there is not a low likelihood for PE, this can be excluded without imaging studies if the D-dimer is below the age-adjusted threshold.

Clinical Presentation and Risk Stratification of Pulmonary Embolism

Pulmonary embolism (PE) presents with a spectrum of symptoms, ranging from asymptomatic cases to life-threatening events. Common symptoms include sudden dyspnea, chest pain, limb swelling, syncope, and hemoptysis. Clinical presentation varies based on thrombus burden, demographics, and time to presentation. Diagnostic evaluation involves assessing symptoms, physical examination findings, and utilizing laboratory tests, including D-dimer. Risk stratification using tools like Wells score, Pulmonary Embolism Severity Index, and Hestia criteria aids in determining the severity of PE. PE is categorized based on hemodynamic status, temporal patterns, and anatomic locations of emboli to guide in making treatment decisions. Risk stratification plays a crucial role in directing management strategies, with elderly and comorbid individuals at higher risk. Early identification and appropriate risk stratification are essential for effective management of PE. As we delve into this review article, we aim to enhance the knowledge base surrounding PE, contributing to improved patient outcomes through informed decision-making in clinical practice.

Clinical Characteristics and Prognosis of Acute Pulmonary Embolism with Hemoptysis in Autoimmune Disease Patients

Background: Hemoptysis is prevalent in acute pulmonary embolism (PE) and significantly influences clinical decision-making. Despite the increasing reports of PE in patients with autoimmune diseases, limited studies have investigated the association between acute PE with hemoptysis and autoimmune disease. Methods: The retrospective study aimed to investigate patients with autoimmune disease who presented with acute PE and hemoptysis at Peking Union Medical College Hospital (PUMCH) between January 2012 and October 2020. A comparative analysis was conducted between patients with and without hemoptysis, as well as between those with autoimmune diseases and those without. Clinical characteristics, PE severity stratification, the amount of hemoptysis, initial anticoagulation management, and prognosis were analyzed descriptively. Results: The study analyzed 896 patients diagnosed with acute PE, of whom 105 (11.7%) presented with hemoptysis. Hemoptysis in PE patients was frequently associated with autoimmune diseases (39%, 41/105), a younger patient population (42.0 vs. 52.7 years old, P =0.002), and a higher prevalence of low-risk PE (53.7 vs. 28.1, P=0.008) compared with non-autoimmune disease patients. Multivariate logistic analysis showed PE patients with primary or metastatic lung cancer, chest pain, age < 48 years old, chronic heart failure, autoimmune disease, pulmonary infection and male were more likely to develop hemoptysis. Patients were grouped based on maximum daily sputum blood volume and PE risk stratification. Most patients (73.2%) received therapeutic-dose anticoagulation. Poor prognosis is observed in patients with moderate to massive hemoptysis and intermediate-high-risk or high-risk PE. Conclusions: Hemoptysis is a relatively common manifestation in patients with PE, and its presence during the diagnostic workup of acute PE necessitates careful analysis of underlying comorbidities. In cases where hemoptysis occurs in individuals with autoimmune diseases in the context of PE, proactive management strategies targeting the primary disease are crucial. Therapeutic decisions should consider both PE severity stratification and the volume of hemoptysis.

Persistent Peril: Recurrent Deep Vein Thrombosis and Pulmonary Embolism in a Patient With Protein S Deficiency Despite Optimal Anticoagulation Therapies

The clotting system has evolved as an adaptive mechanism to prevent blood loss during vascular damage. However, the intricate nature of the clotting cascade and the complexities of human life can sometimes lead to the unnatural activation of this delicate cascade. This can result in blood clot formation within the cardiovascular system, contributing to a wide range of pathological conditions. Abnormal intravascular coagulation most commonly occurs in the deep veins of the lower extremities, and can emboli to other organs, hence, it is termed "venous thromboembolism" (VTE). In this report, we introduce a challenging case of VTE that poses a dilemma for current medical management. The patient with possible protein S deficiency underwent various guideline-directed medical treatments, yet experienced recurrent VTE episodes, including deep vein thrombosis (DVT) and pulmonary embolism (PE), leading to hospital readmissions. This case report sheds light on our challenges in effectively treating VTE.

Intermediate-Risk and High-Risk Pulmonary Embolism: Recognition and Management: Cardiology Clinics: Cardiac Emergencies

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.

Navigating Diagnostic Challenges: Severe Pulmonary Hypertension in Acute Exacerbation of Chronic Obstructive Pulmonary Disease vs. Pulmonary Embolism

A 63-year-old male with an unremarkable medical history presented to the emergency room (ER) with shortness of breath and bilateral lower extremity edema. In the ER, he was found to be hypoxic and hypercapnic on an arterial blood gas. CT angiography of the chest revealed severe emphysematous changes and large right apical bullae. A bedside point-of-care ultrasound demonstrated many bilateral B-lines as well as normal ejection fraction (EF). An echocardiogram revealed a small left ventricular cavity with an EF of 65%, severely dilated right ventricle, severe right ventricular dysfunction, "D" shaped interventricular septum, severely dilated right atrium, and severe pulmonary arterial hypertension (PAH) with a calculated pulmonary artery systolic pressure of 72 mmHg. The patient was initiated on bilevel positive airway pressure, glucocorticoids, bronchodilator nebulization, and diuretics with symptomatic improvement. Herein, this case report discusses similarities and differences between presentations and echocardiographic manifestations of severe PAH in the setting of acute exacerbation of chronic obstructive pulmonary disease and pulmonary embolism in the acute setting.

A Case Report of Under-Recognized Conditions in Pulmonary Embolism: Patent Foramen Ovale and Right Ventricular Thrombus

Pulmonary embolism (PE) is a potentially life-threatening condition that presents with a spectrum of clinical symptoms ranging from asymptomatic to hemodynamic instability. The early diagnosis in the emergency department is often challenging. Although the association between patent foramen ovale (PFO) and thromboembolic events in patients with PE is well-documented, the significance of the presence of PFO in patients with PE may be underrecognized. In addition, the occurrence of right ventricular thrombus (RVT) in PE is a rare but significant complication with implications for disease management. We report a case of acute-on-chronic PE with concurrent bilateral renal infarction due to a paradoxical embolus, alongside RVT. A 35-year-old male presented at our emergency department with complaints of sudden onset abdominal pain. Bilateral renal infarction was identified on a contrast-enhanced computed tomography (CT). Point-of-care ultrasound showed suggestive findings of PE and RVT. Subsequently, a pulmonary CT angiography confirmed bilateral PE, a PFO, and RVT. The patient was effectively managed with thrombolytic therapy, with extracorporeal membrane oxygenation on standby. This case highlights the need to recognize the diverse clinical manifestations of PE and the importance of considering coexisting PFO and RVT in affected patients. The diagnosis of PE can be complex when symptoms overlap with arterial thrombosis, such as renal infarction secondary to a PFO. In addition, RVT, although uncommon, is a serious complication in patients with PE that may require careful evaluation for thrombolytic or anticoagulant therapy. It is critical to consider the possibility of a PFO in all cases of PE, even in the absence of arterial embolism, and to promptly evaluate for RVT prior to initiating treatment.

A clinical proteomics study of exhaled breath condensate and biomarkers for pulmonary embolism

Pulmonary embolism (PE) can be a diagnostic challenge. Current diagnostic markers for PE are unspecific and new diagnostic tools are needed. The air we exhale is a possible new source for biomarkers which can be tapped into by analysing the exhaled breath condensate (EBC). We analysed the EBC from patients with PE and controls to investigate if the EBC is a useful source for new diagnostic biomarkers of PE. We collected and analysed EBC samples from patients with suspected PE and controls matched on age and sex. Patients in whom PE was ruled out after diagnostic work-up were included in the control group to increase the sensitivity and generalizability of the identified markers. EBC samples were collected using an RTube™. The protein composition of the EBCs were analysed using data dependent label-free quantitative nano liquid chromatography-tandem mass spectrometry. EBC samples from 28 patients with confirmed PE, and 49 controls were analysed. A total of 928 EBC proteins were identified in the 77 EBC samples. As expected, a low protein concentration was determined which resulted in many proteins with unmeasurable levels in several samples. The levels of HSPA5, PEBP1 and SFTPA2 were higher and levels of POF1B, EPPK1, PSMA4, ALDOA, and CFL1 were lower in PE compared with controls. In conclusion, the human EBC contained a variety of endogenous proteins and may be a source for new diagnostic markers of PE and other diseases.

Comparison of international guideline recommendations for the diagnosis of pulmonary embolism

Pulmonary embolism is one of the leading causes of death due to cardiovascular disease. Timely diagnosis is crucial, but challenging, as the clinical presentation of pulmonary embolism is unspecific and easily mistaken for other common medical emergencies. Clinical prediction rules and D-dimer measurement allow stratification of patients into groups of expected prevalence and are key elements in adequate selection of patients for diagnostic imaging; however, the strengths and weaknesses of the multiple proposed prediction rules, when to measure D-dimer, and which cutoff to apply might be elusive to a significant proportion of physicians. 13 international guidelines authored by medical societies or expert author groups provide recommendations on facets of the diagnostic investigations in suspected pulmonary embolism, some of which are hallmarked by pronounced heterogeneity. This Review summarises key recommendations of each guideline, considers the most recent evidence on the topic, compares guideline recommendations on each facet of the diagnosis of pulmonary embolism, and provides a synthesis on the most common recommendations.

ECG Features of Pulmonary Embolism in a Patient With Normal D-Dimer and Hypoxia

Pulmonary embolism is a life-threatening condition that requires urgent treatment. We present the case of a 76-year-old male referred to our medical team with dyspnoea, shortness of breath on exertion, and chest pain. Upon further questioning, the patient reported a two-week history of right-sided parasternal pleuritic chest pain without radiation. He denied any history of haemoptysis, calf swelling or pain, recent surgery, and reduced mobility. The patient had a medical history of bilateral cataracts, glaucoma, and hypertension. Clinical examination was unremarkable except for requiring 2L/minute supplemental oxygen to maintain an oxygen saturation of 94%, and blood tests were unremarkable, including a normal D-dimer. Chest radiography revealed no obvious pathological findings. However, the electrocardiogram showed a right bundle branch, sinus tachycardia, and an S1Q3T3 pattern. A computed tomography pulmonary angiogram confirmed pulmonary emboli within the right lower lobe segmental artery, extending into the bilateral basal segmental branch and posterior basal segmental branch. The patient was commenced on low molecular weight heparin initially followed by rivaroxaban 20 mg once daily. This case highlights the importance of having a high degree of suspicion for pulmonary embolism, and D-dimer is an important screening test that can be normal.

Clot Burden As a Predictor of Chronic Thromboembolic Pulmonary Hypertension After Acute Pulmonary Embolism: A Cohort Study

OBJECTIVE

A small percentage of acute pulmonary thromboembolisms (PTE) persist as chronic fibrin clots, potentially leading to chronic thromboembolic pulmonary hypertension (CTEPH). A scoring system for evaluating the burden of acute PTE based on computed tomography pulmonary angiogram (CTPA) findings was tested for its association with CTEPH within one year.

MATERIAL AND METHODS

In this retrospective cohort of 475 patients with a definitive diagnosis of acute PTE, the Qanadli score (QS) was calculated on the initial CTPA. Through regular follow-up over 1 year, symptomatic patients underwent extensive evaluation.

RESULTS

Of the 475 patients enrolled in the study [age 58.3 ± 16.6, 195 (41.1%) female, QS: 13.01 ± 7.37/40], 321 patients completed the study. A total of 22 (6.8%) patients were definitively diagnosed with CTEPH. In univariate analysis, the initial QS was significantly higher in patients with subsequent CTEPH than in patients without (17 ± 5.6 vs. 13 ± 7.6, P = .009). QS was directly associated with CTEPH (odds ratio: 1.08, 95% confidence interval: 1.0-1.16, P = .042). The evolution of CTEPH in men could be predicted with a sensitivity of 100% and a specificity of 54% when a cut-off point of 14.5 (43.5%) was set for QS. The area under the receiver operating characteristic curve in this setting was 0.74 with a P-value of .032. Qanadli score failed to predict CTEPH in women.

CONCLUSION

Scoring the clot burden in the pulmonary arteries through the Qanadli method can predict the evolution of CTEPH only in men 1 year after acute PTE. Women comprise most of the CTEPH patients. Thus, strict follow-up adherence seems to be even more important in women.

Multiorgan ultrasonographic findings in patients with pulmonary embolism at diagnosis and clinical follow-up: a proof of concept study

PURPOSE

The purpose of this descriptive feasibility study was to assess the clinical impact and feasibility of conducting a multiorgan ultrasound examination of patients with pulmonary embolism at both time of diagnosis and at clinical follow-up.

METHODS

Hemodynamically stable patients with pulmonary embolism verified by CT pulmonary angiography or ventilation perfusion scintigraphy were eligible for inclusion. Enrolled patients underwent multiorgan ultrasound investigation encompassing echocardiography supplemented with focused lung and deep venous ultrasound emphasizing right ventricular strain, subpleural consolidations and presence of deep venous thrombi. Identical investigations were conducted at 3 months follow-up. The presence of ultrasonographic findings at diagnosis and follow-up was compared and the clinical impact of any remaining pathology or strain was described.

RESULTS

Twenty-one patients were enrolled in the study of whom 20 survived to attend follow-up. Mean age was 62 ± 15 years and 48% were female. At diagnosis, the most prevalent ultrasonographic findings were subpleural consolidations in 11 patients and right ventricular dilation in eight. At follow-up, signs of right ventricular strain had resolved in all patients. However, in one patient, no resolution was seen in a subpleural consolidation observed at the time of pulmonary embolism diagnosis, resulting in referral to a chest CT. Additionally, one patient exhibited residual deep venous thrombotic material, leading to prolongation of anticoagulative treatment.

CONCLUSION

In patients with pulmonary embolism, multiorgan ultrasound is feasible in follow-up and adequately powered studies should determine the clinical utility of such an approach.

Acute dyspnea in the emergency department: a clinical review

Acute dyspnea represents one of the most frequent symptoms leading to emergency room evaluation. Its significant prognostic value warrants a careful evaluation. The differential diagnosis of dyspnea is complex due to the lack of specificity and the loose association between its intensity and the severity of the underlying pathological condition. The initial assessment of dyspnea calls for prompt diagnostic evaluation and identification of optimal monitoring strategy and provides information useful to allocate the patient to the most appropriate setting of care. In recent years, accumulating evidence indicated that lung ultrasound, along with echocardiography, represents the first rapid and non-invasive line of assessment that accurately differentiates heart, lung or extra-pulmonary involvement in patients with dyspnea. Moreover, non-invasive respiratory support modalities such as high-flow nasal oxygen and continuous positive airway pressure have aroused major clinical interest, in light of their efficacy and practicality to treat patients with dyspnea requiring ventilatory support, without using invasive mechanical ventilation. This clinical review is focused on the pathophysiology of acute dyspnea, on its clinical presentation and evaluation, including ultrasound-based diagnostic workup, and on available non-invasive modalities of respiratory support that may be required in patients with acute dyspnea secondary or associated with respiratory failure.

Clinical presentations of acute pulmonary embolism: A retrospective cohort study

We aimed to investigate whether the unusual clinical presentation of pulmonary embolism (PE) varies by the type of provocation. In this retrospective cohort study, we examined the electronic health records (EHR) records of all patients diagnosed with PE (upon presentation or during hospitalization) presented to our tertiary hospital during 2014 to 2019. Inclusion criteria were the diagnosis of acute PE and age above 18 years. Excluded were all patients to whom complete EHR were not available. The primary outcome was the main presenting symptom, categorized by a multidisciplinary consensus expert committee as either typical or atypical of PE. Comorbidities, vital signs, medications and laboratory results on presentations were recorded. 591 patients were included in the final analysis. Dyspnea was significantly less common and hemoptysis and chest pain more common in the unprovoked PE group (35%, 5%, and 25%, respectively) compared with nonmalignant (42.6%, 0%, and 16.3%) and malignancy-associated (47.7%, 0.9%, and 8.2%) PE (Pv = 0.02, 0.002 and 0.001, respectively). No recorded symptoms were the third most common presentation overall, accounting for a significantly (Pv < 0.001) higher proportion of PE patients with malignancy (19%) whereas atypical presentation was the hallmark of patients with nonmalignant provokation (19.7%) (Pv = 0.005). Accounting for multiple potential confounders, the risk of atypical or asymptomatic presentation was higher with lower heart rates (RR = 0.974 95%C.I. [0.957-0.990]) and higher pulse oximetry saturation (RR = 1.114 95%CI [1.034-1.201]). The clinical presentation of PE varies with different types of provoking factors, with atypical presentation most common in nonmalignant provocation and asymptomatic presentation most prevalent in patients with underlying malignancy. Further studies are needed to determine the effect of said variance on long term clinical outcomes.

To Study the Correlation of Clinical Severity and Cytokine Storm in COVID-19 Pulmonary Embolism Patients by Using Computed Tomography Pulmonary Angiography (CTPA) Qanadli Clot Burden Scoring System

BACKGROUND

Pulmonary embolism (PE) is a fatal form of venous thromboembolism (VTE), with an overall untreated mortality of up to 30%. Greater than 50% of patients with lower extremity proximal DVT have concurrent PE at presentation. VTE has been seen in up to one-third of patients with COVID-19 infections requiring intensive care unit (ICU) admission. The objective of this study is to determine the correlation between CT pulmonary angiography, pulmonary embolism clot burden, and the Qanadli scoring system with clinically severe COVID-19 pneumonia and cytokine storm.

MATERIAL AND METHOD

153 COVID-19 hospitalized patients who underwent CT pulmonary angiography (CTPA) for likely PE on pretest probability modified Wells criteria were enrolled. COVID-19 pneumonia was classified as URTI (upper respiratory tract infection), mild, severe, and critical COVID pneumonia. For data analysis, we categorized into two groups: (1) the non-severe group included URTI and mild pneumonia, and (2) the severe group included severe and critical pneumonia. We used the Qanadli scoring system to assess the PE percentages of pulmonary vascular obstruction using CTPA.  Results: 41.8% (64) of COVID-19 patients were diagnosed with pulmonary embolism (PE) on CTPA. The majority of 51.6% of pulmonary vascular occlusions using the Qanadli scoring system for pulmonary embolism were at segmental arterial levels. Out of 104 COVID-19 cytokine storm patients, 45 (43%) were associated with pulmonary embolism. Overall, a 25% (16) mortality rate was observed in COVID-19 patients with pulmonary embolism.

DISCUSSION

The pathogenesis of hypercoagulability in COVID-19 may include direct endothelial cell invasion by the virus, microvascular inflammation, endothelial exocytosis, and endotheliitis. A meta-analysis of 71 studies to investigate the occurrence of PE on CTPA in COVID-19 patients found 48.6% in ICU settings and 65.3% of patients have clots in the peripheral pulmonary vasculature.

CONCLUSIONS

There is a significant correlation between pulmonary embolism and high clot burden Qanadli CTPA scores, as well as between the severity of COVID-19 pneumonia and mortality. The association between critically ill COVID-19 pneumonia and pulmonary embolism may result in higher mortality and a poor prognostic marker.

Testosterone Usage Leading to Pulmonary Embolisms and Deep Vein Thrombosis: A Case Report and Review of the Literature

Androgen usage has widely increased in recent times via prescribed and unprescribed means. Testosterone is a popular androgen taken by both athletes and the general population. While there is some evidence of androgens being thrombogenic, we report on a 19-year-old male who presented to the hospital after the usage of testosterone for one month, leading to the development of multiple pulmonary emboli and deep vein thrombosis. The authors hope to elucidate the relationship between testosterone usage and thrombosis formation.

Signs and symptoms of acute pulmonary embolism and their predictive value for all-cause hospital death in respect of severity of the disease, age, sex and body mass index: retrospective analysis of the Regional PE Registry (REPER)

BACKGROUND

The incidence of the signs and symptoms of acute pulmonary embolism (PE) according to mortality risk, age and sex has been partly explored.

PATIENTS AND METHODS

A total of 1242 patients diagnosed with acute PE and included in the Regional Pulmonary Embolism Registry were enrolled in the study. Patients were classified as low risk, intermediate risk or high risk according to the European Society of Cardiology mortality risk model. The incidence of the signs and symptoms of acute PE at presentation with respect to sex, age, and PE severity was investigated.

RESULTS

The incidence of haemoptysis was higher in younger men with intermediate-risk (11.7% vs 7.5% vs 5.9% vs 2.3%; p=0.01) and high-risk PE (13.8% vs 2.5% vs 0.0% vs 3.1%; p=0.031) than in older men and women. The frequency of symptomatic deep vein thrombosis was not significantly different between subgroups. Older women with low-risk PE presented with chest pain less commonly (35.8% vs 55.8% vs 48.8% vs 51.9%, respectively; p=0.023) than men and younger women. However, younger women had a higher incidence of chest pain in the lower-risk PE group than in the intermediate-risk and high-risk PE subgroups (51.9%, 31.4% and 27.8%, respectively; p=0.001). The incidence of dyspnoea (except in older men), syncope and tachycardia increased with the risk of PE in all subgroups (p<0.01). In the low-risk PE group, syncope was present more often in older men and women than in younger patients (15.5% vs 11.3% vs 4.5% vs 4.5%; p=0.009). The incidence of pneumonia was higher in younger men with low-risk PE (31.8% vs<16% in the other subgroups, p<0.001).

CONCLUSION

Haemoptysis and pneumonia are prominent features of acute PE in younger men, whereas older patients more frequently have syncope with low-risk PE. Dyspnoea, syncope and tachycardia are symptoms of high-risk PE irrespective of sex and age.

The Challenge of Intermediate-Risk Pulmonary Embolism

BACKGROUND

Intermediate-risk pulmonary embolism is a common disease that is associated with significant morbidity and mortality; however, a standardized treatment protocol is not well-established.

AREAS OF UNCERTAINTY

Treatments available for intermediate-risk pulmonary embolisms include anticoagulation, systemic thrombolytics, catheter-directed therapies, surgical embolectomy, and extracorporeal membrane oxygenation. Despite these options, there is no clear consensus on the optimal indication and timing of these interventions.

THERAPEUTIC ADVANCES

Anticoagulation remains the cornerstone of treatment for pulmonary embolism; however, over the past 2 decades, there have been advances in the safety and efficacy of catheter-directed therapies. For massive pulmonary embolism, systemic thrombolytics and, sometimes, surgical thrombectomy are considered first-line treatments. Patients with intermediate-risk pulmonary embolism are at high risk of clinical deterioration; however, it is unclear whether anticoagulation alone is sufficient. The optimal treatment of intermediate-risk pulmonary embolism in the setting of hemodynamic stability with right heart strain present is not well-defined. Therapies such as catheter-directed thrombolysis and suction thrombectomy are being investigated given their potential to offload right ventricular strain. Several studies have recently evaluated catheter-directed thrombolysis and embolectomies and demonstrated the efficacy and safety of these interventions. Here, we review the literature on the management of intermediate-risk pulmonary embolisms and the evidence behind those interventions.

CONCLUSIONS

There are many treatments available in the management of intermediate-risk pulmonary embolism. Although the current literature does not favor 1 treatment as superior, multiple studies have shown growing data to support catheter-directed therapies as potential options for these patients. Multidisciplinary pulmonary embolism response teams remain a key feature in improving the selection of advanced therapies and optimization of care.

The Effectiveness of a Patient’s Bedside Ultrasonography in Diagnosing a Pulmonary Embolism, in the Emergency Department

Objective:

The research aim was to analyze the function of focused cardiac ultrasonography (FoCUS) in diagnosing a pulmonary embolism (PE) and contributing to the practice of emergency medicine and expediting the treatment of PE.

Materials and Methods:

In this prospective and observational study, Wells scores were calculated on those patients who presented to the emergency department over the last 2 years and were evaluated with a preliminary diagnosis of PE, as well as the biochemical values and imaging techniques. In all cases, FoCUS was used as the diagnostic tool.

Results:

A PE was detected in 38 (63.3%) of 60 patients. According to Wells score, it was determined that 5 (8.3%) patients had low-risk, 41 (68.3%) had medium-risk, and 14 (23.3%) had high-risk Wells score. There was a statistically significant correlation between the existence of PE and the findings of FoCUS in patients with right ventricular dilatation ( P < .001). According to Wells score, moderate-risk individuals with PE were more likely to exhibit right ventricular dilatation ( P = .003).

Conclusion:

The FoCUS results either alone or in conjunction with the Wells score, reviewed in the diagnosis of PE, effectively indicated and directed the diagnosis and treatment of patients admitted to this particular emergency department.

Contemporary interventional management of pulmonary embolism

Minimally invasive interventional techniques are being utilised more frequently in the management of acute and chronic pulmonary emboli; however, robust clinical evidence is only emerging for the utilisation of these techniques. Hence, there is a need for a robust mechanism of patient selection and careful consideration of the benefits and risks of the interventions. In this review, we discuss the risk stratification mechanisms; the role of the multidisciplinary pulmonary embolism response team to support decision-making; and describe the various commonly used interventional techniques and how these can be integrated into treatment strategies for the benefit of our patients.

Diagnostic Accuracy of a Bespoke Multiorgan Ultrasound Approach in Suspected Pulmonary Embolism

Purpose The aims of this study were to prospectively assess the diagnostic accuracy of a bespoke multiorgan point-of-care ultrasound approach for suspected pulmonary embolism and evaluate if this model allows reduced referral to further radiation diagnostics while maintaining safety standards. Materials and Methods Patients with suspected pulmonary embolism referred for CT pulmonary angiography or ventilation/perfusion scintigraphy were included as a convenience sample. All patients were subject to blinded ultrasound investigation with cardiac, lung, and deep venous ultrasound. The sensitivity and specificity of applied ultrasound signs and the hypothetical reduction in the need for further diagnostic workup were calculated. Results 75 patients were prospectively enrolled. The Wells score was below 2 in 48 patients, between 2 and 6 in 24 patients, and above 6 in 3 patients. The prevalence of pulmonary embolism was 28%. The most notable ultrasound signs were presence of a deep venous thrombus, at least two hypoechoic pleural-based lesions, the D-sign, the 60/60-sign, and a visible right ventricular thrombus which all had a specificity of 100%. Additionally, a multiorgan ultrasound investigation with no findings compatible with pulmonary embolism yielded a sensitivity of 95.2% (95%CI: 76.2-99.9). CT or scintigraphy could be safely avoided in 70% of cases (95%CI: 63.0-83.1%). Conclusion The findings of our study suggest that implementation of a multiorgan ultrasound assessment in patients with suspected pulmonary embolism may safely reduce the need for CT or scintigraphy by confirming or dismissing the suspicion.

Pulmonary embolism presenting as delirium: an acute confusional state in an elderly patient-a case report

Background

Large numbers of elderly patients are admitted to hospitals in acute confusional states. In many, the underlying causes are easily found; in some, correct diagnosis is difficult. Pulmonary embolism (PE), the most serious clinical presentation of venous thromboembolism, is often misdiagnosed because of its non-specific features including delirium.

Case presentation

A 73-year-old woman was admitted to our hospital in a confused state with no obvious risk factors of PE. D-dimer levels were elevated and contrast-enhanced high-resolution computed tomography (HRCT) of the chest confirmed the diagnosis of PE. She was treated with enoxaparin and discharged on dabigatran. Her symptoms had resolved at the time of discharge, and she has been stable for over three month's follow-up visit.

Conclusion

PE should be regarded as a differential in elderly patients with an acute confusional state despite the absence of obvious risk factors. Investigating for and treating when confirmed may save a life.

Prognostic value of fragmented QRS in acute pulmonary embolism: a cross-sectional-analytic study of the Iranian population

BACKGROUND

Acute Pulmonary embolism (APE) is considered one of the deadliest cardiovascular diseases. Electrocardiographic (ECG) abnormalities in pulmonary embolism (PE) are increasingly reported. A growing number of studies have recommended that ECG plays a crucial role in the prognostic assessment of PE patients. However, there is scarce data on the prognostic importance of fragmented QRS (fQRS) on outcomes in patients with APE. This study aims to investigate the prognostic value of fQRS in APE patients.

MATERIALS AND METHODS

This is a cross-sectional-analytic study. This study included 280 patients diagnosed with APE admitted to Shahid Madani hospital, Tabriz, Iran. Computed tomography pulmonary angiography (CTPA) was used to diagnose APE. A checklist was prepared for all patients, demographic, clinical characteristics, and Major Adverse Cardiopulmonary events (MACPE), including in-hospital mortality, need for thrombolysis, mechanical ventilation, and surgical embolectomy, were recorded. Patients were divided into two groups: patients who manifested fQRS on their ECG and patients who did not; Then, demographic, clinical characteristics, and MACPE were compared in the two groups, as mentioned earlier. Furthermore, all statistical analyses were carried out using SPSS software.

RESULTS

48 patients (17.14%) had fQRS(+) on their ECG, and 232 patients (82.86%) did not have it on their ECG. In data analysis, 22 patients (8.7%) had in-hospital mortality, 35 patients (13.9%) needed thrombolysis, nine patients (3.9%) required mechanical ventilation, and 13 patients (5.1%) needed surgical embolectomy. fQRS was not significantly associated with in-hospital mortality (P = 0.225), need for thrombolysis (P = 0.684), mechanical ventilation (P = 1.000), and surgical embolectomy (P = 1.000). Demographic and clinical characteristics were also similar in both groups.

CONCLUSIONS

This study does not support the idea that fQRS on ECG is a valuable predictor of in-hospital mortality, the need for thrombolysis, mechanical ventilation, and surgical embolectomy.

Impact of clinical profile at admission on the outcomes in patients hospitalized for acute pulmonary embolism: data from the IPER Registry

Acute pulmonary embolism (PE) is characterized by a large heterogeneity of clinical presentation and disease course. We investigate whether different symptom PE phenotypes in hemodynamically stable PE could be associated with 30-day mortality risk. Hemodynamically stable patients from the multicentre, prospective Italian Pulmonary Embolism Registry (IPER) (September 2006-August 2010) presenting the most common four clinical phenotypes (< 24 h onset dyspnoea, chest pain, pleuritic pain and phlebitis) at admission were included and compared to those who were asymptomatic at admission. Overall, 1365 (mean age 68.7 ± 15.3 years, 609 males) were evaluated. Recent onset dyspnoea (< 24 h), chest pain, pleuritic pain and phlebitis were observed in 28.4%, 19.7%, 12.9% and 25.2%, respectively while asymptomatic patients represented the remaining 13.6% of cases. PE presenting with recent dyspnoea onset and chest pain had a lower 30-day overall survival (log-rank p = 0.01 and p < 0.001, respectively). By contrast, there were no significant differences when comparing patients with pleuritic pain or phlebitis (log-rank p = 0.2). Similar findings were confirmed at the Cox multivariate regression analysis which indicated a higher mortality risk in patients with chest pain [HR 3.21, 95% CI 2.16-4.78, p < 0.001] or recent dyspnoea [HR 2.12, 95% CI 1.22-3.87, p = 0.002] independent of age, heart rate, presence of right ventricular dysfunction, positive cardiac troponin and administration of systemic thrombolysis. Hemodynamically stable PE patients presenting with chest pain or recent onset dyspnoea had a lower 30-day survival compared to those asymptomatic or presenting pleuritic or phlebitis pain.Trial registry ClinicalTrials.gov; No: NCT01604538).

Prevalence of pulmonary embolism among patients with recent onset of dyspnea on exertion. A cross-sectional study

BACKGROUND

Exertional dyspnea is a frequently encountered complaint in clinical practice. However, the prevalence of pulmonary embolism (PE) among patients with dyspnea on exertion has not been reported.

OBJECTIVE

The objective of this study was to assess the prevalence of objectively confirmed PE among consecutive patients visiting an emergency department because of recent onset of exertional dyspnea.

METHODS

Patients aged ≤75 years with recent (<1 month) marked exertional dyspnea had a systematic workup for PE, irrespective of concomitant signs or symptoms of venous thromboembolism and alternative explanations for dyspnea. PE was excluded on the basis of a low pretest clinical probability and normal age-adjusted D-dimer. All other patients had computed tomography pulmonary angiography. An interim analysis after inclusion of 400 patients would stop recruitment if the 95% confidence interval (CI) of the PE prevalence had a lower limit exceeding 20%.

RESULTS

The study was prematurely terminated after the inclusion of 417 patients. In 134 patients (32.1%), PE was excluded based on low clinical probability and normal D-dimer. PE was found in 134 (47.3%) of the remaining 283 patients, for an overall prevalence of 32.1% (95% CI, 27.8-36.8). PE was present in 40 of 204 (19.6%) patients without other findings suspicious for PE and in 94 of 213 patients (44.1%) with such findings. PE involved a main pulmonary artery in 37% and multiple lobes in 87% of the patients.

CONCLUSION

The angiographic demonstration of PE is common in patients presenting with recent onset of marked exertional dyspnea, including 20% without other findings suggesting pulmonary embolism.

Pulmonary Embolism and Respiratory Deterioration in Chronic Cardiopulmonary Disease: A Narrative Review

Patients with chronic cardiopulmonary pathologies have an increased risk of developing venous thromboembolic events. The worsening of dyspnoea is a frequent occurrence and often leads patients to consult the emergency department. Pulmonary embolism can then be an exacerbation factor, a differential diagnosis or even a secondary diagnosis. The prevalence of pulmonary embolism in these patients is unknown, especially in cases of chronic heart failure. The challenge lies in needing to carry out a systematic or targeted diagnostic strategy for pulmonary embolism. The occurrence of a pulmonary embolism in patients with chronic cardiopulmonary disease clearly worsens their prognosis. In this narrative review, we study pulmonary embolism and chronic obstructive pulmonary disease, after which we turn to pulmonary embolism and chronic heart failure.

A case of massive pulmonary embolism causing cardiac arrest managed with successful systemic thrombolytic in the emergency department

Pulmonary Embolism (PE), when complicated by cardiac arrest, is almost always fatal despite all resuscitative efforts. However, a more favorable is possible when PE is rapidly identified as the cause of cardiac arrest and pulmonary circulation is quickly re-established by specific therapy. A 54-year-old woman was brought to the Emergency Department (ED) by 112 emergency ambulance service with the complaint of shortness of breath that had started 2 hours ago. She developed cardiac arrest while being physical examined 2 minutes after admission, and Cardiopulmonary Resuscitation (CPR) was immediately begun. Massive PE was considered the most likely diagnosis in the light of her history, physical examined, and bedside ultrasonography findings; thus, recombinant tissue Plasminogen Activator (r-tPA) was administered during CPR. The second CPR attempt achieved return of spontaneous circulation within 5 minutes. She was treated at intensive care unit for 32 days and discharged from the hospital with complete recovery.

Seizure as the clinical presentation of massive pulmonary embolism: Case report and literature review

Massive pulmonary embolism (MPE) is a high-risk medical emergency. Seizure as the clinical presentation of MPE is extremely rare, and to our knowledge, there have been no reports on successful percutaneous, catheter-based treatment of MPE presenting with new-onset seizures and cardiac arrest. In this report, we discuss the case of a 64-year-old woman who presented with an episode of seizure that lasted 5 h. Seizure occurred four times within 12 h after arrival at the hospital, and in the end, she sustained a cardiac arrest. The patient had no past history of seizure or cardiopulmonary disease. Bilateral MPE was detected by a computed tomography pulmonary angiogram, and she was successfully treated with percutaneous, catheter-directed anticoagulant therapy. Pulmonary embolism-related seizures are more difficult to diagnose and have higher mortality rates than seizures. MPE should be suspected in patients presenting with new-onset seizures and hemodynamic instability.

Massive pulmonary embolism with ST-segment elevation mimicking an isolated right ventricular myocardial infarction in a patient with COVID-19 pneumonia: Case report

Pulmonary embolism (PE) is a great simulator; It mimics step by step its main differential diagnosis which is myocardial infarction. Its clinical and electrical manifestations are unspecific. Rarely, an ST-segment elevation can occur making the diagnosis more difficult. Recognizing such an uncommon electrocardiographic (ECG) pattern is of an important relevance to lead to a prompt and suitable therapeutic management. In our paper, we discuss a 68 years-old man case who presents with dyspnea and chest pain with ST-segment elevation in V1, aVR, DIII, and right-sided leads suggestive of isolated right ventricular infarction, admitted in a stable hemodynamical status which rapidly deteriorated. Echocardiographic assessment has shown signs of acute pulmonary heart disease with the presence of the specific McConnell's sign. A computed tomography pulmonary angiogram was performed revealing massive bilateral PE that benefited from thrombolytic therapy with alteplase with a remarkable following and regression of the ST-segment elevation. To our knowledge, this is the first case report of massive PE presenting with these ECG findings in the context of COVID 19 pneumonia, of which practitioners should be aware to better orient diagnosis and therapeutic management.

How we dealt with the double whammy! Acute pulmonary embolism with abdominal aortic clot and renal infarcts

Pulmonary embolism (PE) is the third most common cause of cardiovascular mortality in the United States, and the submassive PE accounts for 20%-25% of all acute PE. In the last decade, endovascular therapy with catheter-directed thrombolysis (CDT) intervention has shown great success in the treatment of submassive PE. There is limited data regarding using these devices to treat patients with concomitant abdominal aortic and renal vessel clots. Herein, we present a case of a 23-year-old male who presented with submassive PE associated with abdominal aortic thrombosis and renal infarcts. The patient was successfully treated with CDT with complete resolution of pulmonary and bilateral renal artery clots.

Augmentation of literature review of COVID-19 radiology

We suggest an augmentation of the excellent comprehensive review article titled “Comprehensive literature review on the radiographic findings, imaging modalities, and the role of radiology in the coronavirus disease 2019 (COVID-19) pandemic” under the following categories: (1) “Inclusion of additional radiological features, related to pulmonary infarcts and to COVID-19 pneumonia”; (2) “Amplified discussion of cardiovascular COVID-19 manifestations and the role of cardiac magnetic resonance imaging in monitoring and prognosis”; (3) “Imaging findings related to fluorodeoxyglucose positron emission tomography, optical, thermal and other imaging modalities/devices, including ‘intelligent edge’ and other remote monitoring devices”; (4) “Artificial intelligence in COVID-19 imaging”; (5) “Additional annotations to the radiological images in the manuscript to illustrate the additional signs discussed”; and (6) “A minor correction to a passage on pulmonary destruction”.

Dilemmas in the Choice of Adequate Therapeutic Treatment in Patients with Acute Pulmonary Embolism—From Modern Recommendations to Clinical Application

Pulmonary thromboembolism is a very common cardiovascular disease, with a high mortality rate. Despite the clear guidelines, this disease still represents a great challenge both in diagnosis and treatment. The heterogeneous clinical picture, often without pathognomonic signs and symptoms, represents a huge differential diagnostic problem even for experienced doctors. The decisions surrounding this therapeutic regimen also represent a major dilemma in the group of patients who are hemodynamically stable at initial presentation and have signs of right ventricular (RV) dysfunction proven by echocardiography and positive biomarker values (pulmonary embolism of intermediate–high risk). Studies have shown conflicting results about the benefit of using fibrinolytic therapy in this group of patients until hemodynamic decompensation, due to the risk of major bleeding. The latest recommendations give preference to new oral anticoagulants (NOACs) compared to vitamin K antagonists (VKA), except for certain categories of patients (patients with antiphospholipid syndrome, mechanical valves, pregnancy). When using oral anticoagulant therapy, special attention should be paid to drug–drug interactions, which can lead to many complications, even to the death of the patient. Special population groups such as pregnant women, obese patients, patients with antiphospholipid syndrome and the incidence of cancer represent a great therapeutic challenge in the application of anticoagulant therapy. In these patients, not only must the effectiveness of the drugs be taken into account, but great attention must be paid to their safety and possible side effects, which is why a multidisciplinary approach is emphasized in order to provide the best therapeutic option.

10,589 CT pulmonary angiograms: evaluating the yield of acute pulmonary embolism

OBJECTIVES

To evaluate the change in the number of CT pulmonary angiograms (CTPAs) performed and the change in the yield of acute pulmonary embolism (PE) on CTPA at a busy tertiary teaching hospital from 2016 to 2019.

METHODS

All CTPA examinations for both in-patients and emergency department patients performed at our busy tertiary teaching hospital between 1 January 2016 and 31 December 2019 were identified from the radiology information system. A natural language processing technique called phrase matching was employed to assign each of the examination reports a result of either positive, negative or equivocal for acute PE. This algorithm was validated on a sample of 200 reports.

RESULTS

The number of CTPAs performed increased 59% from 2016 to 2019. The overall yield of acute PE has remained steady averaging 15.9%, ranging from 15.0% to 17.2%.

CONCLUSIONS

Over 3 years, there has been a significant increase in the demand for CTPA examinations. The yield of acute PE has remained steady indicating a justified increase in demand. The yield of acute PE on CTPA within our centre is higher than the Royal College of Radiologists' suggested minimum of 15.4% which suggests the current guidelines used for the investigation of suspected acute PE within our centre are appropriate.

ADVANCES IN KNOWLEDGE

The guidelines and subsequent yield of acute PE on CTPA at our tertiary teaching hospital can be used as a reference standard for other similar institutes.

Pulmonary Embolism in Women: A Systematic Review of the Current Literature

Cardiovascular disease is the leading cause of death in women. Pulmonary embolism (PE) is the third most-common cause of cardiovascular death, after myocardial infarction (MI) and stroke. We aimed to evaluate the attributes and outcomes of PE specifically in women and explore sex-based differences. We conducted a systematic review of the literature using electronic databases PubMed and Embase up to 1 April 2022 to identify studies investigating PE in women. Of the studies found, 93 studies met the eligibility criteria and were included. The risk of PE in older women (especially >40 years of age) superseded that of age-matched men, although the overall age- and sex-adjusted incidence of PE was found to be lower in women. Risk factors for PE in women included age, rheumatologic disorders, hormone replacement therapy or oral contraceptive pills, pregnancy and postpartum period, recent surgery, immobilization, trauma, increased body mass index, obesity, and heart failure. Regarding pregnancy, a relatively higher incidence of PE has been observed in the immediate postpartum period compared to the antenatal period. Women with PE tended to be older, presented more often with dyspnea, and were found to have higher NT-proBNP levels compared to men. No sex-based differences in in-hospital mortality and 30-day all-cause mortality were found. However, PE-related mortality was higher in women, particularly in hemodynamically stable patients. These differences form the basis of future research and outlets for reducing the incidence, morbidity, and mortality of PE in women.

A visualized pulmonary arterial thrombus by using a modified echocardiographic view in an intermediate-risk acute pulmonary embolism patient: A case report

Acute pulmonary embolism (APE) is a life‐threatening disease with nonspecific clinical signs and symptoms. Rapid and accurate diagnosis is crucial for the clinical management of patients with acute pulmonary embolism. A recommended echocardiography view may be of further help in the diagnosis and evaluation of the change in thrombosis and treatment. We reported a case of a 74‐year‐old man with a 12‐day history of decreased exercise capacity and dyspnea. The patient was diagnosed with intermediate‐risk APE as several pulmonary emboli in pulmonary artery were seen in multidetector computed tomographic pulmonary angiography with normal blood pressure and echocardiographic right ventricular overload. And we found a pulmonary artery clot in the right pulmonary artery through transthoracic echocardiography. After 11‐days anticoagulation, the patient underwent a reassessment, showed a decrease in RV diameter and pulmonary artery thrombus. This case highlights the significant role that echocardiography played in a patient who presented pulmonary embolism with a stable hemodynamic situation and normal blood pressure. The modified echocardiographic view could provide correct diagnosis by identifying the clot size and location visually. Knowledge of the echocardiography results of APE would aid the diagnosis.

Characteristics and Outcomes of Patients Consulted by a Multidisciplinary Pulmonary Embolism Response Team: 5-Year Experience

(1) Background: Pulmonary embolism (PE) is the third most frequent acute cardiovascular condition worldwide. PE response teams (PERTs) have been created to facilitate treatment implementation in PE patients. Here, we report on the 5-year experience of PERT operating in Warsaw, Poland, with regard to the characteristics and outcomes of the consulted patients. (2) Methods: Patients diagnosed with PE between September 2017 and December 2021 were included in the study. Clinical and treatment data were obtained from medical records. Patient outcomes were assessed in-hospital, at a 1- and 12-month follow-up. (3) Results: There were 235 PERT activations. The risk of early mortality was low in 51 patients (21.8%), intermediate–low in 83 (35.3%), intermediate–high in 80 (34.0%) and high in 21 (8.9%) patients. Anticoagulation alone was the most frequently administered treatment in all patient subgroups (altogether 84.7%). Systemic thrombolysis (47.6%) and interventional therapy (52%) were the prevailing treatment options in high-risk patients. The in-hospital mortality was 6.4%. The adverse events during 1-year follow-up included five deaths, two recurrent VTE and two minor bleeding events. (4) Conclusions: Our initial 5-year experience showed that the activity of the local PERT facilitated patient-tailored decision making and the access to advanced therapies, with subsequent low overall mortality and treatment complication rates, confirming the benefits of PERT implementation.

Pulmonary embolism and renal artery thrombosis in a patient with patent foramen ovale

BACKGROUND AND AIM

Paradoxical embolism is a rare condition in which a thrombus migrates from the venous system to the arterial circulation, usually through a patent foramen ovale (PFO). Pulmonary embolism (PE) and isolated occlusion of one renal artery has been seldom reported.

METHODS

We describe a case of a 47-year old white man with a one-month history of exertional dyspnea who was admitted to our hospital for  severe pain in the right lumbar region.

RESULTS

A computed tomography showed  PE and a thrombotic occlusion of the right renal artery. A trans-thoracic echocardiogram documented a PFO with right to left shunt. Magnetic resonance imaging of the brain and venous compression ultrasonography of the lower extremities were normal. Therapeutic anticoagulation was started.

CONCLUSIONS

Pulmonary embolism and thrombotic occlusion of one renal artery is a rare manifestation of paradoxical embolism. Exertional dyspnea is an atypical manifestation of PE and can delay the diagnosis.

Validation of the Swedish National Inpatient Register for the diagnosis of pulmonary embolism in 2005

The Swedish National Inpatient Register (NPR) has near‐complete coverage of in‐hospital admissions and ICD codes in Sweden. Acute pulmonary embolism (PE) is a serious condition presenting challenges regarding diagnosis, treatment, and follow‐up. Here we aimed to validate the accuracy of acute PE diagnosis in the NPR, investigational findings, antithrombotic treatment, and follow‐up of PE patients in Sweden. From a nation‐wide cohort of all patients with in‐hospital diagnoses of acute PE (ICD‐10‐SE codes I26.0–I26.9) in 2005 (n = 5793), we selected those from two Swedish regions for thorough manual review of hospital records. We identified 599 patients with PE diagnoses according to the ICD‐10 coding system. We excluded 58 patients with admissions related to previous PE (47; 8%) or incorrect ICD codes (11; 2%), leaving 501 patients with probable PE diagnoses. We confirmed the diagnosis in 441 (79%) cases, which was based on imaging (435 patients; 73%) or autopsy (6; 1%). In the remaining 60 (11%) cases, the PE diagnosis was based on clinical findings and can therefore not be confirmed. Of the surviving patients with PE, 231 (47%) were offered follow‐up within 6 months after the acute event. At follow‐up, 67 patients (29%) had symptoms requiring clinical attention (dyspnoea or reduced general condition). The Swedish NPR showed acceptable accuracy for PE diagnosis, and could be reliably used for register‐based research regarding acute PE.

Circulating MicroRNAs for Diagnosis of Acute Pulmonary Embolism: Still a Long Way to Go

Venous thromboembolism (VTE) represents the third most frequent cause of acute cardiovascular syndrome. Among VTE, acute pulmonary embolism (APE) is the most life-threatening complication. Due to the low specificity of symptoms clinical diagnosis of APE may be sometimes very difficult. Accordingly, the latest European guidelines only suggest clinical prediction tests for diagnosis of APE, eventually associated with D-dimer, a biomarker burdened by a very low specificity. A growing body of evidence is highlighting the role of miRNAs in hemostasis and thrombosis. Due to their partial inheritance and susceptibility to the environmental factors, miRNAs are increasingly described as active modifiers of the classical Virchow's triad. Clinical evidence on deep venous thrombosis reported specific miRNA signatures associated to thrombosis development, organization, recanalization, and resolution. Conversely, data of miRNA profiling as a predictor/diagnostic marker of APE are still preliminary. Here, we have summarized clinical evidence on the potential role of miRNA in diagnosis of APE. Despite some intriguing insight, miRNA assay is still far from any potential clinical application. Especially, the small sample size of cohorts likely represents the major limitation of published studies, so that extensive analysis of miRNA profiles with a machine learning approach are warranted in the next future. In addition, the cost-benefit ratio of miRNA assay still has a negative impact on their clinical application and routinely test.

D-Dimer Tests in the Emergency Department: Current Insights

In the Emergency Medicine setting, D-dimer is currently employed in the diagnostic assessment of suspected venous thromboembolism and aortic syndrome. The nonspecific symptoms reported by patients, like chest pain, dyspnea or syncope, uncover a wide range of differential diagnosis, spanning from mild to life-threatening conditions. Therefore, we assumed the perspective of the Emergency Physician and, in this narrative review, we reported a brief presentation of the epidemiology of these symptoms and the characteristics of patients, in whom we could suspect the aforementioned pathologies. We also reported in which patients D-dimer gives useful information. In fact, when the probability of the disease is high, the D-dimer level is futile. On the contrary, given the low specificity of the test, when the probability of the disease is very low, a false-positive value of the D-dimer only increases the risk of overtesting. Patients with low to moderate probability really benefit from the D-dimer testing, in order to prevent the execution of expensive and potentially dangerous imaging tests. In the second part of the review, we focused on the prognostic value of the test in septic patients. The early prognostic stratification of septic patients remains a challenge for the Emergency Physician, in the absence of a definite biomarker or score to rely on. Therefore, we need several parameters for the early identification of patients at risk of an adverse prognosis and the D-dimer may play a role in this demanding task. SARS COVID-19 patients represent an emerging reality, where the role of the D-dimer for prognostic stratification could be relevant. In fact, in patients with severe forms of this disease, the D-dimer reaches very high values, which appear to parallel the course of respiratory failure. Whether the test may add useful information for the management of these patients remains to be determined.

Prevalence and predictors of pulmonary embolism in patients with acute exacerbation of chronic obstructive pulmonary disease

Background:

The prevalence of pulmonary embolism (PE) in patients of acute exacerbation of chronic obstructive pulmonary disease (AECOPD) varies over a wide range. Early detection and treatment of PE in AECOPD is a key to improve patient outcome. The purpose of the study was to investigate the prevalence and predictors of PE in patients of AECOPD in a high burden region of North India.

Materials and Methods:

This prospective study included patients of AECOPD with no obvious cause of exacerbation on initial evaluation. Apart from routine workup, the participants underwent assessment of D-dimer, compression ultrasound and venous Doppler ultrasound of the lower limbs and pelvic veins, and a multidetector computed tomography pulmonary angiography.

Results:

A total of 100 patients of AECOPD with unknown etiology were included. PE as a possible cause of AE-COPD was observed in 14% of patients. Among the participants with PE, 63% (n = 9) had a concomitant presence of lower extremity deep venous thrombosis. Hemoptysis and chest pain were significantly higher in patients of AECOPD with PE ([35.7% vs. 7%, P = 0.002] and [92.9% vs. 38.4%, P = 0.001]). Likelihood of PE was significantly higher in patients who presented with tachycardia, tachypnea, respiratory alkalosis (PaCO2 <45 mmHg and pH >7.45), and hypotension. No difference was observed between the two groups in terms of in-hospital mortality, age, sex distribution, and risk factors for embolism except for the previous history of venous thromboembolism (35.7% vs. 12.8% P = 0.03).

Conclusion:

PE was probably responsible for AECOPD in 14% of patients with no obvious cause on initial assessment. Patients who present with chest pain, hemoptysis, tachypnea, tachycardia, and respiratory alkalosis should be particularly screened for PE.

Development and validation of a novel risk assessment model to estimate the probability of pulmonary embolism in postoperative patients

Pulmonary embolism (PE) is a leading cause of mortality in postoperative patients. Numerous PE prevention clinical practice guidelines are available but not consistently implemented. This study aimed to develop and validate a novel risk assessment model to assess the risk of PE in postoperative patients. Patients who underwent Grade IV surgery between September 2012 and January 2020 (n = 26,536) at the Affiliated Dongyang Hospital of Wenzhou Medical University were enrolled in our study. PE was confirmed by an identified filling defect in the pulmonary artery system in CT pulmonary angiography. The PE incidence was evaluated before discharge. All preoperative data containing clinical and laboratory variables were extracted for each participant. A novel risk assessment model (RAM) for PE was developed with multivariate regression analysis. The discrimination ability of the RAM was evaluated by the area under the receiver operating characteristic curve, and model calibration was assessed by the Hosmer–Lemeshow statistic. We included 53 clinical and laboratory variables in this study. Among them, 296 postoperative patients developed PE before discharge, and the incidence rate was 1.04%. The distribution of variables between the training group and the validation group was balanced. After using multivariate stepwise regression, only variable age (OR 1.070 [1.054–1.087], P < 0.001), drinking (OR 0.477 [0.304–0.749], P = 0.001), malignant tumor (OR 2.552 [1.745–3.731], P < 0.001), anticoagulant (OR 3.719 [2.281–6.062], P < 0.001), lymphocyte percentage (OR 2.773 [2.342–3.285], P < 0.001), neutrophil percentage (OR 10.703 [8.337–13.739], P < 0.001), red blood cell (OR 1.872 [1.384–2.532], P < 0.001), total bilirubin (OR 1.038 [1.012–1.064], P < 0.001), direct bilirubin (OR 0.850 [0.779–0.928], P < 0.001), prothrombin time (OR 0.768 [0.636–0.926], P < 0.001) and fibrinogen (OR 0.772 [0.651–0.915], P < 0.001) were selected and significantly associated with PE. The final model included four variables: neutrophil percentage, age, malignant tumor and lymphocyte percentage. The AUC of the model was 0.949 (95% CI 0.932–0.966). The risk prediction model still showed good calibration, with reasonable agreement between the observed and predicted PE outcomes in the validation set (AUC 0.958). The information on sensitivity, specificity and predictive values according to cutoff points of the score in the training set suggested a threshold of 0.012 as the optimal cutoff value to define high-risk individuals. We developed a new approach to select hazard factors for PE in postoperative patients. This tool provided a consistent, accurate, and effective method for risk assessment. This finding may help decision-makers weigh the risk of PE and appropriately select PE prevention strategies.

Diagnostic accuracy of focused deep venous, lung, cardiac and multiorgan ultrasound in suspected pulmonary embolism: a systematic review and meta-analysis

OBJECTIVE

To determine the diagnostic accuracy of point-of-care ultrasound in suspected pulmonary embolism.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE, Embase, CINAHL and Cochrane library were searched on 2 July 2020 with no restrictions on the date of publication. Subject headings or subheadings combined with text words for the concepts of pulmonary embolism, ultrasound and diagnosis were used.

ELIGIBILITY CRITERIA AND DATA ANALYSIS

Eligible studies reported sensitivity and specificity of deep venous, lung, cardiac or multiorgan ultrasound in patients with suspected pulmonary embolism, using an adequate reference-test. Prospective, cross-sectional and retrospective studies were considered for eligibility. No restrictions were made on language. Studies were excluded if a control group consisted of healthy volunteers or if transesophageal or endobronchial ultrasound was used. Risk of bias was assessed using quality assessment of diagnostic accuracy studies-2. Meta-analysis of sensitivity and specificity was performed by construction of hierarchical summary receiver operator curves. I² was used to assess the study heterogeneity.

MAIN OUTCOME MEASURES

The primary outcome was overall sensitivity and specificity of reported ultrasound signs, stratified by organ approach (deep venous, lung, cardiac and multiorgan). Secondary outcomes were stratum-specific sensitivity and specificity within subgroups defined by pretest probability of pulmonary embolism.

RESULTS

6378 references were identified, and 70 studies included. The study population comprised 9664 patients with a prevalence of pulmonary embolism of 39.9% (3852/9664). Risk of bias in at least one domain was found in 98.6% (69/70) of included studies. Most frequently, 72.8% (51/70) of studies reported >24 hours between ultrasound examination and reference test or did not disclose time interval at all. Level of heterogeneity ranged from 0% to 100%. Most notable ultrasound signs were bilateral compression of femoral and popliteal veins (22 studies; 4708 patients; sensitivity 43.7% (36.3% to 51.4%); specificity 96.7% (95.4% to 97.6%)), presence of at least one hypoechoic pleural-based lesion (19 studies; 2134 patients; sensitivity 81.4% (73.2% to 87.5%); specificity 87.4% (80.9% to 91.9%)), D-sign (13 studies; 1579 patients; sensitivity 29.7% (24.6% to 35.4%); specificity 96.2% (93.1% to 98.0%)), visible right ventricular thrombus (5 studies; 995 patients; sensitivity 4.7% (2.7% to 8.1%); specificity 100% (99.0% to 100%)) and McConnell's sign (11 studies; 1480 patients; sensitivity 29.1% (20.0% to 40.1%); specificity 98.6% (96.7% to 99.4%)).

CONCLUSION

Several ultrasound signs exhibit a high specificity for pulmonary embolism, suggesting that implementation of ultrasound in the initial assessment of patients with suspected pulmonary embolism may improve the selection of patients for radiation imaging.

PROSPERO REGISTRATION NUMBER

CRD42020184313.

Hemithorax Westermark Sign Secondary to Complete Pulmonary Artery Occlusion from Pulmonary Embolus

Case Presentation

We describe a complete right hemithorax Westermark sign found in a patient with a near-complete, right pulmonary artery trunk occlusion secondary to a pulmonary embolus.

Discussion

We review the sensitivity and specificity of a Westermark sign in the identification of a pulmonary embolism, and how this aided us in managing our patient in the emergency department.