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Glazier MM, Glazier JJ. Diagnostic Strategies in Pulmonary Embolism. Int J Angiol 2024; 33:89-94. [PMID: 38846998 PMCID: PMC11152624 DOI: 10.1055/s-0044-1779661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2024] Open
Abstract
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.
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Affiliation(s)
| | - James J. Glazier
- Department of Medicine, Wayne State University School of Medicine, Detroit, Michigan
- Department of Cardiology, Oakland University William Beaumont School of Medicine, Rochester, Michigan
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Arrigo M, Price S, Harjola VP, Huber LC, Schaubroeck HAI, Vieillard-Baron A, Mebazaa A, Masip J. Diagnosis and treatment of right ventricular failure secondary to acutely increased right ventricular afterload (acute cor pulmonale): a clinical consensus statement of the Association for Acute CardioVascular Care of the European Society of Cardiology. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:304-312. [PMID: 38135288 PMCID: PMC10927027 DOI: 10.1093/ehjacc/zuad157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 12/18/2023] [Accepted: 12/20/2023] [Indexed: 12/24/2023]
Abstract
Acute right ventricular failure secondary to acutely increased right ventricular afterload (acute cor pulmonale) is a life-threatening condition that may arise in different clinical settings. Patients at risk of developing or with manifest acute cor pulmonale usually present with an acute pulmonary disease (e.g. pulmonary embolism, pneumonia, and acute respiratory distress syndrome) and are managed initially in emergency departments and later in intensive care units. According to the clinical setting, other specialties are involved (cardiology, pneumology, internal medicine). As such, coordinated delivery of care is particularly challenging but, as shown during the COVID-19 pandemic, has a major impact on prognosis. A common framework for the management of acute cor pulmonale with inclusion of the perspectives of all involved disciplines is urgently needed.
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Affiliation(s)
- Mattia Arrigo
- Department of Internal Medicine, Stadtspital Zurich, Birmensdorferstrasse 497, 8063 Zürich, Switzerland
| | - Susanna Price
- Royal Brompton Hospital, National Heart & Lung Institute, Imperial College London, London, UK
| | - Veli-Pekka Harjola
- Department of Emergency Medicine, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Lars C Huber
- Department of Internal Medicine, Stadtspital Zurich, Birmensdorferstrasse 497, 8063 Zürich, Switzerland
| | | | | | - Alexandre Mebazaa
- Department of Anesthesia, Burn and Critical Care Medicine, AP-HP, Hôpitaux Universitaires Saint-Louis-Lariboisière, FHU PROMICE, INI-CRCT, and Université de Paris, MASCOT, Inserm, Paris, France
| | - Josep Masip
- Research Direction, Consorci Sanitari Integral, University of Barcelona, Barcelona, Spain
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Láinez-Ramos-Bossini A, Moreno-Suárez S, Pérez-García M, Gálvez-López R, Garrido Sanz F, Rivera-Izquierdo M. Acute pulmonary embolism: Appropriateness of emergency department management according to clinical guidelines. RADIOLOGIA 2022; 64:291-299. [DOI: 10.1016/j.rxeng.2020.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 06/26/2020] [Indexed: 10/18/2022]
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Arrigo M, Huber LC. Right ventricle assessment in patients with pulmonary embolism: low risk = low yield for systematic echocardiography. Eur Heart J 2021; 43:84-85. [PMID: 34788419 DOI: 10.1093/eurheartj/ehab762] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Mattia Arrigo
- Department of Internal Medicine, Stadtspital Zurich Triemli, Birmensdorferstrasse 497, 8063 Zurich, Switzerland.,University of Zurich, Raemistrasse 71, 8006 Zurich, Switzerland
| | - Lars C Huber
- Department of Internal Medicine, Stadtspital Zurich Triemli, Birmensdorferstrasse 497, 8063 Zurich, Switzerland.,University of Zurich, Raemistrasse 71, 8006 Zurich, Switzerland
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Arrigo M, Huber LC. Pulmonary Embolism and Heart Failure: A Reappraisal. Card Fail Rev 2021; 7:e03. [PMID: 33708418 PMCID: PMC7926477 DOI: 10.15420/cfr.2020.26] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 10/30/2020] [Indexed: 12/20/2022] Open
Abstract
Acute heart failure and acute pulmonary embolism share many features, including epidemiological aspects, clinical presentation, risk factors and pathobiological mechanisms. As such, it is not surprising that diagnosis and management of these common conditions might be challenging for the treating physician, in particular when both are concomitantly present. While helpful guidelines have been elaborated for both acute heart failure and pulmonary embolism, not many studies have been published on the coexistence of these diseases. With a special focus on diagnostic tools and therapeutic options, the authors review the available literature and, when evidence is lacking, present their own approach to the management of dyspnoeic patients with acute heart failure and pulmonary embolism.
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Affiliation(s)
- Mattia Arrigo
- Department of Internal Medicine, Triemli Hospital Zurich Zurich, Switzerland
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Láinez-Ramos-Bossini AJ, Moreno-Suárez S, Pérez-García MC, Gálvez-López R, Sanz FG, Rivera-Izquierdo M. Acute pulmonary embolism: appropriateness of emergency department management according to clinical guidelines. RADIOLOGIA 2020; 64:S0033-8338(20)30111-9. [PMID: 33008620 DOI: 10.1016/j.rx.2020.06.004] [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: 03/25/2020] [Revised: 06/11/2020] [Accepted: 06/26/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND AIMS To evaluate the frequency of acute pulmonary embolism, the use of clinical probability scores, and the appropriateness of the management of patients for whom computed tomography angiography (CTA) was requested from the emergency department for suspected acute pulmonary embolism. MATERIALS AND METHODS This was a retrospective observational study of CTA studies requested from the emergency department to rule out acute pulmonary embolism. We analyzed clinical variables and the explicit use of clinical probability scores. We determined the appropriateness of management according to the Wells Score and Geneva Score and the simplified versions of these two scores, calculated retrospectively. RESULTS We included 534 patients (52.8% women; mean age, 73 years). The frequency of acute pulmonary embolism was 23.0% and the Wells Score was explicitly used in 15.2%. The appropriateness of the management varied depending on the clinical probability score used to assess it (54.5%-75.8%) and on whether the standard D-dimer or age-adjusted D-dimer was used. CONCLUSIONS The failure to use the Wells Scores in all cases does not necessarily imply inappropriate management, and the performance of global clinical judgment can be similar to that of clinical probability scores; however, specific studies are necessary to confirm this hypothesis.
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Affiliation(s)
- A J Láinez-Ramos-Bossini
- Servicio de Radiodiagnóstico, Hospital Universitario Virgen de las Nieves, Granada, España; Programa de Doctorado en Medicina Clínica y Salud Pública, Universidad de Granada, Granada, España.
| | - S Moreno-Suárez
- Servicio de Urgencias, Hospital Universitario Virgen de las Nieves, Granada, España
| | - M C Pérez-García
- Servicio de Radiodiagnóstico, Hospital Universitario Virgen de las Nieves, Granada, España
| | - R Gálvez-López
- Servicio de Urgencias, Hospital Universitario Virgen de las Nieves, Granada, España
| | - F Garrido Sanz
- Servicio de Radiodiagnóstico, Hospital Universitario Virgen de las Nieves, Granada, España
| | - M Rivera-Izquierdo
- Servicio de Radiodiagnóstico, Hospital Universitario Virgen de las Nieves, Granada, España; Servicio de Medicina Preventiva y Salud Pública, Hospital Universitario San Cecilio, Granada, España
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Jolobe OMP. What Are the Parameters That Should Inform Gestalt as a Clinical Decision Strategy for Pulmonary Embolism? Am J Med 2020; 133:e61. [PMID: 31954476 DOI: 10.1016/j.amjmed.2019.06.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 06/19/2019] [Indexed: 10/25/2022]
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Patel JJ, Bergl PA. Illuminating Gestalt in Diagnosing Acute Pulmonary Embolism. Am J Med 2020; 133:e62-e63. [PMID: 31954477 DOI: 10.1016/j.amjmed.2019.08.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 08/28/2019] [Indexed: 11/17/2022]
Affiliation(s)
- Jayshil J Patel
- Associate Professor of Medicine, Division of Pulmonary & Critical Care Medicine, Curriculum Pillar Faculty, Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education, Medical College of Wisconsin, Milwaukee.
| | - Paul A Bergl
- Assistant Professor of Medicine, Division of Pulmonary & Critical Care Medicine, Medical College of Wisconsin, Milwaukee
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Stüssi-Helbling M, Arrigo M, Huber LC. The Reply. Am J Med 2020; 133:e64. [PMID: 31954478 DOI: 10.1016/j.amjmed.2019.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 09/17/2019] [Indexed: 11/24/2022]
Affiliation(s)
- Melina Stüssi-Helbling
- Department of Internal Medicine, Clinic for Internal Medicine, City Hospital Triemli Zurich, Switzerland.
| | - Mattia Arrigo
- Division of Cardiology, University Hospital Zurich, Switzerland
| | - Lars C Huber
- Department of Internal Medicine, Clinic for Internal Medicine, City Hospital Triemli Zurich, Switzerland
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