Effect of delay in hospital presentation on clinical and imaging findings in acute pulmonary thromboembolism

A new nomogram prediction model for pulmonary embolism in older hospitalized patients

Purpose

Diagnosing pulmonary embolism (PE) in older adults is relatively difficult because of the atypical clinical symptoms of PE in older adults accompanied by multiple complications. This study aimed to establish a nomogram model to better predict the occurrence of PE in older adults.

Methods

Data were collected from older patients (≥65 years old) with suspected PE who were hospitalized between January 2012 and July 2021 and received confirmatory tests (computed tomographic pulmonary angiography or ventilation/perfusion scanning). The PE group and non-PE (control) group were compared using univariable and multivariable analyses to identify independent risk factors. A nomogram prediction model was constructed with independent risk factors and verified internally. The effectiveness of the nomogram model, Wells score, and revised Geneva score was assessed using the area under the receiver operating characteristic curve (AUC).

Results

In total, 447 eligible older patients (290 PE patients and 157 non-PE patients) were enrolled. Logistic regression analysis revealed nine independent risk factors: smoking, inflammation, dyspnea, syncope, mean corpuscular hemoglobin concentration, indirect bilirubin, uric acid, left atrial diameter, and internal diameter of the pulmonary artery. The AUC, sensitivity, and specificity of the nomogram prediction model were 0.763 (95 % confidence interval, 0.721-0.802), 74.48 %, and 67.52 %, respectively. The nomogram showed superior AUC compared to the Wells score (0.763 vs. 0.539, P < 0.0001) and the revised Geneva score (0.763 vs. 0.605, P < 0.0001).

Conclusions

This novel nomogram may be a useful tool to better recognize PE in hospitalized older adults.

A systematic review and meta-analysis of diagnostic delay in pulmonary embolism

Background

Diagnostic delay in patients with pulmonary embolism (PE) is typical, yet the proportion of patients with PE that experienced delay and for how many days is less well described, nor are determinants for such delay.

Objectives

This study aimed to assess the prevalence and extent of delay in diagnosing PE.

Methods

A systematic literature search was performed to identify articles reporting delays in diagnosing PE. The primary outcome was mean delay (in days) or a percentage of patients with diagnostic delay (defined as PE diagnosis more than seven days after symptom onset). The secondary outcome was determinants of delay. Random-effect meta-analyses were applied to calculate a pooled estimate for mean delay and to explore heterogeneity in subgroups.

Results

The literature search yielded 10,933 studies, of which 24 were included in the final analysis. The pooled estimate of the mean diagnostic delay based on 12 studies was 6.3 days (95% prediction interval 2.5 to 15.8). The percentage of patients having more than seven days of delay varied between 18% and 38%. All studies assessing the determinants of coughing (n = 3), chronic lung disease (n = 6) and heart failure (n = 8) found a positive association with diagnostic delay. Similarly, all studies assessing recent surgery (n = 7) and hypotension (n = 6), as well as most studies assessing chest pain (n = 8), found a negative association with diagnostic delay of PE.

Conclusion

Patients may have symptoms for almost one week before PE is diagnosed and in about a quarter of patients, the diagnostic delay is even longer.

Diagnostic Delay of Pulmonary Embolism in COVID-19 Patients

Pulmonary embolism (PE) is a frequent, life-threatening COVID-19 complication, whose diagnosis can be challenging because of its non-specific symptoms. There are no studies assessing the impact of diagnostic delay on COVID-19 related PE. The aim of our exploratory study was to assess the diagnostic delay of PE in COVID-19 patients, and to identify potential associations between patient- or physician-related variables and the delay. This is a single-center observational retrospective study that included 29 consecutive COVID-19 patients admitted to the San Matteo Hospital Foundation between February and May 2020, with a diagnosis of PE, and a control population of 23 non-COVID-19 patients admitted at our hospital during the same time lapse in 2019. We calculated the patient-related delay (i.e., the time between the onset of the symptoms and the first medical examination), and the physician-related delay (i.e., the time between the first medical examination and the diagnosis of PE). The overall diagnostic delay significantly correlated with the physician-related delay (p < 0.0001), with the tendency to a worse outcome in long physician-related diagnostic delay (p = 0.04). The delay was related to the presence of fever, respiratory symptoms and high levels of lactate dehydrogenase. It is important to rule out PE as soon as possible, in order to start the right therapy, to improve patient's outcome and to shorten the hospitalization.

Does Baseline BUN Have an Additive Effect on the Prediction of Mortality in Patients with Acute Pulmonary Embolism?

Background: In patients with heart failure, elevated levels of blood urea nitrogen (BUN) is a prognostic factor. In this study, we investigated the prognostic value of elevated baseline BUN in short-term mortality among patients with acute pulmonary embolism (PE). Methods: Between 2007 and 2014, cardiac biomarkers and BUN levels were measured in patients with acute PE. The primary endpoint was 30-day mortality, evaluated based on the baseline BUN (≥14 ng/L) level in 4 groups of patients according to the European Society of Cardiology's risk stratification (low-risk, intermediate low-risk, intermediate high-risk, and high-risk). Results: Our study recruited 492 patients with a diagnosis of acute PE (mean age=60.58±16.81 y). The overall 1-month mortality rate was 6.9% (34 patients). Elevated BUN levels were reported in 316 (64.2%) patients. A high simplified pulmonary embolism severity index (sPESI) score (OR: 5.23, 95% CI: 1.43-19.11; P=0.012), thrombolytic or thrombectomy therapy (OR: 2.42, 95% CI: 1.01-5.13; P=0.021), and elevated baseline BUN levels (OR: 1.04, 95% CI: 1.01-1.03; P=0.029) were the independent predictors of 30-day mortality. According to our receiver-operating characteristics analysis for 30-day mortality, a baseline BUN level of greater than 14.8 mg/dL was considered elevated. In the intermediate-low-risk patients, mortality occurred only in those with elevated baseline BUN levels (7.2% vs. 0; P=0.008). Conclusion: An elevated baseline BUN level in our patients with PE was an independent predictor of short-term mortality, especially among those in the intermediate-risk group.

Effect of Using an Age-adjusted D-dimer to Assess for Pulmonary Embolism in Community Emergency Departments

BACKGROUND

The objective of this study was to evaluate the effect of changing the laboratory-reported D-dimer reference intervals to age-adjusted reference intervals on the use of advanced chest imaging and 30-day adverse events among emergency department (ED) encounters.

METHODS

A retrospective interrupted time-series analysis of ED encounters for patients > 50 years evaluated for suspected pulmonary embolism (PE) from April 2014 to April 2016. The primary outcome was use of advanced diagnostic imaging, and the secondary outcome was 30-day mortality or PE diagnosis. Secondary analyses also quantified delayed PE diagnoses pre- and postintervention. A generalized estimating equation segmented logistic regression model, adjusting for patient and facility characteristics, was used to determine changes in odds of diagnostic imaging and 30-day mortality or PE diagnoses.

RESULTS

A total of 10,534 (5,153 pre- and 5,381 postimplementation) ED encounters were included. Advanced imaging was obtained in 35.9% of pre- versus 33% of postimplementation encounters. Age-adjusted D-dimer (AADD) showed a small and nonsignificant decrease in month-to-month trends of advanced chest imaging postimplementation (odds ratio [OR] = 0.98, 95% confidence interval [CI] = 0.96 to 1.00). Use of advanced imaging in patients with D-dimer values lower than 500 ng/mL fibrinogen-equivalent units (FEU) was similar in the preintervention (5.8%) and postintervention (6.8%) periods. However, imaging was obtained in 30% of patients postintervention with a D-dimer result less than AADD reference interval , but more than the historical 500 ng/mL FEU reference interval. Implementing an AADD threshold demonstrated no change in the rate of 30-day adverse events (missed PE or mortality).

CONCLUSION

Changing the laboratory-reported D-dimer reference intervals for evaluation of PE was not associated with reduction in advanced chest imaging and did not increase 30-day adverse events. However, there was substantial noncompliance with the age-adjusted reference intervals in the postintervention period likely blunting the impact of this intervention.

Relationship of Lower-extremity Deep Venous Thrombosis Density at CT Venography to Acute Pulmonary Embolism and the Risk of Postthrombotic Syndrome

Background Acute deep venous thrombi (DVT) have higher Hounsfield unit values than chronic (bland) thrombi at CT venography. Purpose To determine the relationship between DVT thrombus density found on CT venography images to the presence of acute pulmonary embolism (PE) and the future risk of postthrombotic syndrome (PTS) in patients with DVT. Materials and Methods In this retrospective study, patients were divided into two groups: PE with DVT group and DVT-only group. Wells scores were recorded. Thrombus density ratios were calculated (DVT thrombus Hounsfield units/surrounding vein Hounsfield units). The presence or absence of PTS was determined from the results of the Venous Insufficiency Epidemiologic and Economic Study on Quality of Life (VEINES-QOL) questionnaires given to the patients with DVT. Statistical analyses used receiver operating characteristic curves and Spearman correlation analyses. Results Eighty-six patients were included; the mean age was 60 years ± 17 (51 men; PE with DVT group, 54 patients [63%]; DVT-only group, 32 patients [37%]). The mean thrombus density ratio was significantly higher in the PE with DVT group than in the DVT-only group (53.6% ± 12.4 [standard deviation] vs 42.8% ± 11.9, respectively; P < .001). At multivariable analysis, Wells score greater than 4 (odds ratio, 12.0; 95% confidence interval [CI]: 3.0, 47; P < .001) and higher thrombus density ratio (odds ratio, 1.1; 95% CI: 1.0, 1.2; P = .001) were independent predictors of PE. The diagnostic performance for the thrombus density ratio (area under the receiver operating characteristic curve, 0.74; 95% CI: 0.63, 0.85; P < .001) may be more discriminative than that of the Wells score (area under the receiver operating characteristic curve, 0.70; 95% CI: 0.59, 0.81; P = .002) for the presence of PE. In subgroup analysis, the thrombus density ratio and VEINES-QOL score were correlated (r = 0.61; 95% CI: 0.30, 0.80; P < .001). Conclusion Deep venous thrombosis (DVT) density ratio at CT venography was associated with acute pulmonary embolism in patients with lower-extremity DVT. © RSNA, 2019 Online supplemental material is available for this article.

Determinants and prognostic implication of diagnostic delay in patients with a first episode of pulmonary embolism

Signs and symptoms of pulmonary embolism (PE) are not specific and this can lead to a diagnostic delay. Little is known about the determinants of this delay and its prognostic implication. We conducted a retrospective analysis of a prospective cohort involving 514 patients with a first episode of PE. The diagnostic delay was defined as a time from first symptom onset to diagnosis of >3 days, corresponding of the median time in the population. Multivariable logistic regression analysis was performed to identify determinants of diagnostic delay. Prognostic implication was measured as the occurrence of 30-day all-cause mortality, haemodynamic collapse or recurrent PE. A total of 240 (47%) among 514 patients had a time from first symptom to diagnosis > 3 days. Previous deep vein thrombosis (OR 0.55, 95% Confidence Interval (CI), 0.32-0.93), immobilization (OR 0.52, 95% CI, 0.28-0.96), surgery (OR 0.31, 95% CI, 0.16-0.62), chest pain (OR 0.58, 95% CI, 0.39-0.86), syncope (OR 0.48, 95% CI, 0.23-1.01), dyspnea (OR 2.48, 95% CI, 1.57-3.91) and hemoptysis (OR 3.57, 95% CI, 1.40-9.07) were associated with diagnostic delay. Twenty-two patients (4.3%, 95%CI, 2.8-6.5) experienced an outcome event within 30 days. Among them, 15 patients (6.2% 95%CI, 3.7-10.3) had a diagnostic delay and 7 (2.6%, 95% CI 1.1-5.4) did not (p = 0.039). In this cohort, diagnostic delay is associated with the absence of major risk factors for PE or clinical features such as chest pain or syncope and the presence of dyspnea or hemoptysis. Diagnostic delay is associated with a worse 30-day prognosis.