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Mohammed AQI, Berman L, Staroselsky M, Wenn P, Hai O, Makaryus AN, Zeltser R. Clinical Presentation and Risk Stratification of Pulmonary Embolism. Int J Angiol 2024; 33:82-88. [PMID: 38846996 PMCID: PMC11152639 DOI: 10.1055/s-0044-1786878] [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
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.
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Affiliation(s)
| | - Lorin Berman
- Department of Cardiology, Nassau University Medical Center, East Meadow, NY
| | - Mark Staroselsky
- Department of Cardiology, Nassau University Medical Center, East Meadow, NY
| | - Peter Wenn
- Department of Cardiology, Nassau University Medical Center, East Meadow, NY
| | - Ofek Hai
- Department of Cardiology, Nassau University Medical Center, East Meadow, NY
| | - Amgad N. Makaryus
- Department of Cardiology, Nassau University Medical Center, East Meadow, NY
- Department of Cardiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Roman Zeltser
- Department of Cardiology, Nassau University Medical Center, East Meadow, NY
- Department of Cardiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
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Xiong W, Zhao Y, Cheng Y, Du H, Sun J, Wang Y, Xu M, Guo X. Comparison of VTE risk scores in guidelines for VTE diagnosis in nonsurgical hospitalized patients with suspected VTE. Thromb J 2023; 21:8. [PMID: 36658654 PMCID: PMC9850809 DOI: 10.1186/s12959-023-00450-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 01/09/2023] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND The assessment of VTE likelihood with VTE risk scores is essential prior to imaging examinations during VTE diagnostic procedure. Little is known with respect to the disparity of predictive power for VTE diagnosis among VTE risk scores in guidelines for nonsurgical hospitalized patients with clinically suspected VTE. METHODS A retrospective study was performed to compare the predictive power for VTE diagnosis among the Wells, Geneva, YEARS, PERC, Padua, and IMPROVE scores in the leading authoritative guidelines in nonsurgical hospitalized patients with suspected VTE. RESULTS Among 3168 nonsurgical hospitalized patients with suspected VTE, VTE was finally excluded in 2733(86.3%) ones, whereas confirmed in 435(13.7%) ones. The sensitivity and specificity resulted from the Wells, Geneva, YEARS, PERC, Padua, and IMPROVE scores were (90.3%, 49.8%), (88.7%, 53.6%), (73.8%, 50.2%), (97.7%,16.9%), (80.9%, 44.0%), and (78.2%, 47.0%), respectively. The YI were 0.401, 0.423, 0.240, 0.146, 0.249, and 0.252 for the Wells, Geneva, YEARS, PERC, Padua, and IMPROVE scores, respectively. The C-index were 0.694(0.626-0.762), 0.697(0.623-0.772), 0.602(0.535-0.669), 0.569(0.486-0.652), 0.607(0.533-0.681), and 0.609(0.538-0.680) for the Wells, Geneva, YEARS, PERC, Padua, and IMPROVE scores, respectively. Consistency was significant in the pairwise comparison of Wells vs Geneva(Kappa 0.753, P = 0.565), YEARS vs Padua(Kappa 0.816, P = 0.565), YEARS vs IMPROVE(Kappa 0.771, P = 0.645), and Padua vs IMPROVE(Kappa 0.789, P = 0.812), whereas it did not present in the other pairs. The YI was improved to 0.304, 0.272, and 0.264 for the PERC(AUC 0.631[0.547-0.714], P = 0.006), Padua(AUC 0.613[0.527-0.700], P = 0.017), and IMPROVE(AUC 0.614[0.530-0.698], P = 0.016), with a revised cutoff of 5 or less, 6 or more, and 4 or more denoting the VTE-likely, respectively. CONCLUSIONS For nonsurgical hospitalized patients with suspected VTE, the Geneva and Wells scores perform best, the PERC scores performs worst despite its significantly high sensitivity, whereas the others perform intermediately, albeit the absolute predictive power of all isolated scores are mediocre. The predictive power of the PERC, Padua, and IMPROVE scores are improved with revised cutoffs.
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Affiliation(s)
- Wei Xiong
- grid.412987.10000 0004 0630 1330Department of Pulmonary and Critical Care Medicine, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, No. 1665, Kongjiang Road, Yangpu District, Shanghai, 200092 China
| | - Yunfeng Zhao
- grid.459502.fDepartment of Pulmonary and Critical Care Medicine, Pudong New District, Punan Hospital, Shanghai, China
| | - Yi Cheng
- grid.412987.10000 0004 0630 1330Department of Pulmonary and Critical Care Medicine, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, No. 1665, Kongjiang Road, Yangpu District, Shanghai, 200092 China
| | - He Du
- grid.412532.3Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jinyuan Sun
- grid.412987.10000 0004 0630 1330Department of Pulmonary and Critical Care Medicine, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, No. 1665, Kongjiang Road, Yangpu District, Shanghai, 200092 China
| | - Yanmin Wang
- grid.412987.10000 0004 0630 1330Department of Pulmonary and Critical Care Medicine, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, No. 1665, Kongjiang Road, Yangpu District, Shanghai, 200092 China
| | - Mei Xu
- Department of General Practice, North Bund Community Health Service Center, Hongkou District, Shanghai, China
| | - Xuejun Guo
- grid.412987.10000 0004 0630 1330Department of Pulmonary and Critical Care Medicine, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, No. 1665, Kongjiang Road, Yangpu District, Shanghai, 200092 China
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Di Vilio A, Vergara A, Desiderio A, Iodice F, Serio A, Palermi S, Gambardella F, Sperlongano S, Gioia R, Acitorio M, D'Andrea A. Incremental value of compression ultrasound sonography in the emergency department. World J Crit Care Med 2021; 10:194-203. [PMID: 34616656 PMCID: PMC8462022 DOI: 10.5492/wjccm.v10.i5.194] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 04/13/2021] [Accepted: 07/05/2021] [Indexed: 02/06/2023] Open
Abstract
The quick evaluation of venous thromboembolism is a key point of modern medicine since the delayed diagnosis is associated with a worse prognosis. Venous ultrasound (VU) is a sensitive and rapidly performed test in cases of suspected deep venous thrombosis. Various protocols have been proposed for its execution, such as the study of the whole deep venous circulation of the lower limb or the analysis of the femoral-popliteal area. The aim is to detect a vessel thrombus and the most sensitive element is the non-compressibility with the probe. Initially, the thrombus is hypoechogenic and adherent to the vessel; later, it tends to organize and recanalize. Usually, in the early stages, the risk of embolism is higher. The role of studying the iliac axis and calf veins is still uncertain. VU is not useful for assessing response to anticoagulation therapy and it is unclear whether the persistence of thrombotic abnormalities can guide on a possible prolongation of therapy.
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Affiliation(s)
- Alessandro Di Vilio
- Unit of Cardiology and Intensive Coronary Care, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, Naples 80131, Italy
| | - Andrea Vergara
- Unit of Cardiology and Intensive Coronary Care, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, Naples 80131, Italy
| | - Alfonso Desiderio
- Unit of Cardiology and Intensive Coronary Care, Umberto I Hospital, Nocera Inferiore 84014, Italy
| | - Franco Iodice
- Unit of Cardiology and Intensive Coronary Care, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, Naples 80131, Italy
| | - Alessandro Serio
- Human Anatomy and Sport Medicine Division, Department of Public Health, University of Naples “Federico II”, Naples 80131, Italy
| | - Stefano Palermi
- Human Anatomy and Sport Medicine Division, Department of Public Health, University of Naples “Federico II”, Naples 80131, Italy
| | - Francesco Gambardella
- Human Anatomy and Sport Medicine Division, Department of Public Health, University of Naples “Federico II”, Naples 80131, Italy
| | - Simona Sperlongano
- Unit of Cardiology and Intensive Coronary Care, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, Naples 80131, Italy
| | - Renato Gioia
- Department of Medicine, Surgery, and Dentistry, University of Salerno, Salerno 84084, Italy
| | - Maria Acitorio
- Unit of Cardiology and Intensive Coronary Care, Umberto I Hospital, Nocera Inferiore 84014, Italy
| | - Antonello D'Andrea
- Unit of Cardiology and Intensive Coronary Care, Umberto I Hospital, Nocera Inferiore 84014, Italy
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Combination of the Simplified Modified Geneva and Wells Clinical Prediction Scoring promise a good performance in pulmonary embolism diagnosis. JOURNAL OF SURGERY AND MEDICINE 2021. [DOI: 10.28982/josam.962221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Ossei PPS, Owusu IK, Owusu-Asubonteng G, Ankobea-Kokroe F, Ayibor WG, Niako N. Prevalence of Venous Thromboembolism in Kumasi: A Postmortem-Based Study in a Tertiary Hospital in Ghana. CLINICAL MEDICINE INSIGHTS-CIRCULATORY RESPIRATORY AND PULMONARY MEDICINE 2020; 14:1179548420956364. [PMID: 33117036 PMCID: PMC7573747 DOI: 10.1177/1179548420956364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 08/13/2020] [Indexed: 11/15/2022]
Abstract
Background There is a dearth of publications on the prevalence of venous thromboembolism in Ghana. Knowledge of the prevalence of venous thromboembolism, which is often undetected clinically, will help save lives as appropriate interventions can be made as well as provide a general clue to clinicians on detecting venous thromboembolism and pulmonary embolism. Methods The study employs a retrospective design with data extracted from the Autopsy Daybook of the Pathology unit, Komfo Anokye Teaching Hospital, 2009 to 2016. Data on patients' demographics were retrieved to establish diagnoses and age and gender distribution. Analysis was made of pulmonary embolism and deep vein thrombosis as a cause of death recorded on death certificates using the criteria of the International Classification of Diseases, version 10. Results A total of 150 cases of deep vein thrombosis and/or pulmonary embolism were available for the study period and the results showed an average age of 45.3 years with a standard deviation of 19.96. The ages ranged between 3 years and 96 years with the age group 31 to 40 years being the modal age group. Males recorded the highest number of cases with 92 (59.35%) compared to females with 63 (40.65%). Respiratory disorders, of which pneumonia is the most prevalent, are the leading clinical condition that is often misdiagnosed in place of pulmonary thromboembolism. Conclusion VTE is a major health problem especially among the elderly, but unfortunately the clinical diagnosis is usually missed by clinicians hence the need to maintain a high suspicion index.
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Affiliation(s)
- Paul Poku Sampene Ossei
- Department of Pathology, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Isaac Kofi Owusu
- Department of Medicine, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Gerald Owusu-Asubonteng
- Department of Obstetrics & Gynecology, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Frank Ankobea-Kokroe
- Department of Obstetrics & Gynecology, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - William Gilbert Ayibor
- Department of Molecular Medicine, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Nicholas Niako
- Department of Pathology, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
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Coelho J, Divernet-Queriaud M, Roy PM, Penaloza A, Le Gal G, Trinh-Duc A. Comparison of the Wells score and the revised Geneva score as a tool to predict pulmonary embolism in outpatients over age 65. Thromb Res 2020; 196:120-126. [PMID: 32862033 DOI: 10.1016/j.thromres.2020.07.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 07/09/2020] [Accepted: 07/09/2020] [Indexed: 12/14/2022]
Abstract
TITLE Comparison of the Wells score and the revised Geneva score as a tool to predict pulmonary embolism in outpatients over 65 years of age. INTRODUCTION The incidence and mortality of pulmonary embolism (PE) is high in the elderly. The Wells score (SW) and the revised Geneva score (RGS) have been validated in patient populations with a large age range. The aim of this study was to compare the predictive accuracy of these two scores in diagnosis of PE in patients over 65 years of age. METHOD A prospective multicentre study (nine French and three Belgian centres) was conducted at the same time as the PERCEPIC study. A total of 1757 patients admitted with suspected PE were included and divided into two groups according to age (≥65 years or <65 years). The pre-test probability of PE was assessed prospectively for the RGS. The SW was calculated retrospectively. The predictive accuracy of the two scores was compared by the area under the curve (AUC) of the ROC curves. RESULTS The overall prevalence of PE was 11.3%. The prevalence among patients aged ≥65 in the low, moderate and high pre-test probability groups, evaluated using the WS and was respectively 13.5% (CI 95%: CI 9.9-17.3), 28.2% (CI 22.1-34.3), 50% (CI 26-74) and 8.1% (CI 3.2-12.9), 22.3% (CI 18.2-26.3), 43.7% (CI 25.6-61.9) using the RGS. The AUC for the WS and RGS for patients aged ≥65 was 0.632 (CI 0.574-0.691) and 0.610 (CI 0.555-0.666). The difference between the AUCs was not statistically significant (p = .441). CONCLUSION In the population for this study, the WS and RGS have the same PE diagnostic accuracy in patients over age 65. This result should be validated in a prospective study that directly compares these scores.
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Affiliation(s)
- Julien Coelho
- Centre Hospitalier d'Agen-Nérac, Site St Esprit, 21 route de Villeneuve, 47923 Agen, France.
| | | | - Pierre-Marie Roy
- Emergency Department, Centre Hospitalier Universitaire Angers, Institut Mitovasc, Université d'Angers, Angers, France
| | - Andréa Penaloza
- Emergency Department, Cliniques Universitaires St-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Grégoire Le Gal
- Division of Hematology-Thrombosis Program, Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Albert Trinh-Duc
- Centre Hospitalier d'Agen-Nérac, Site St Esprit, 21 route de Villeneuve, 47923 Agen, France
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Songur Yücel Z, Metin aksu N, Akkaş M. The combined use of end-tidal carbon dioxide and alveolar dead space fraction values in the diagnosis of pulmonary embolism. Pulmonology 2020; 26:192-197. [DOI: 10.1016/j.pulmoe.2019.11.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 11/22/2019] [Accepted: 11/26/2019] [Indexed: 12/16/2022] Open
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Zhao B, Hao B, Xu H, Premaratne S, Zhang J, Jiao L, Zhang W, Wang S, Su X, Sun L, Yao J, Yu Y, Yang T. Predictive Model for Pulmonary Embolism in Patients with Deep Vein Thrombosis. Ann Vasc Surg 2020; 66:334-343. [PMID: 31911130 DOI: 10.1016/j.avsg.2019.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 11/26/2019] [Accepted: 12/02/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND To develop and verify a risk predictive model/scoring system for pulmonary embolism (PE) among hospitalized patients with deep venous thrombosis of the lower extremities (LDVT). METHODS 776 patients with LDVT were enrolled in a case-control study between January 2016 and June 2017 from the Vascular Surgery Department of Shanxi Dayi Hospital, China. They were randomly divided into development (543 patients, 70%) and validation (233 patients, 30%) databases. Based on the results of pulmonary computed tomography arteriography, patients were divided into 2 categories; those with PE were designated as the case group, whereas those without comprised the controls. A logistic regression model and scoring system for PE in patients with LDVT was established in the development database and verified in the validation database. Scoring system (Shanxi Dayi Hospital score [SDH score]) was tabulated as follows: right lower extremity or bilateral lower extremities, 1; surgery or immobilization, 1; malignant tumor, 1; history of venous thromboembolism (VTE), 2; D-dimer >1,000 ng/mL, 2; and unprovoked, 2. Calibration and discrimination of the model were assessed by the Hosmer-Lemeshow goodness of fit test and the area under the receiver operating characteristic curve (AUC). Wells score, the Revised Geneva score, and the SDH score for predictive value of PE by AUC in the validation database were compared. RESULTS 776 patients with LDVT were divided into 2 risk categories based on the scores from the risk model as follows: PE unlikely (score <3) and PE likely (score ≥3). Sensitivity, specificity, and crude agreement of the SDH score in the development database were 76.39%, 55.89%, and 61.33%, respectively. In the validation database, the logistic regression model showed good calibration and discriminative power. The Hosmer-Lemeshow goodness of fit test P value was >0.05, and the AUC was 0.705 (95% CI: 0.634-0.776, P < 0.001). The SDH score also showed good discriminative power, and the AUC was 0.702 (95% CI: 0.631-0.774, P < 0.001). Sensitivity, specificity, and crude agreement of the SDH score in the validation database were 67.61%, 61.73%, and 63.52%, respectively. AUC for the Wells score and the Revised Geneva score was 0.611 (95% CI: 0.533-0.688, P = 0.007) and 0.585 (95% CI: 0.503-0.666, P = 0.040), respectively. Difference of the AUC was not statistically significant between the Wells score and the SDH score (0.611 vs. 0.702, P = 0.059) but was so between the Revised Geneva score and the SDH score (0.585 vs. 0.702, P = 0.016). Sensitivity of the Wells score, Revised Geneva score, and the SDH score (64.79%, 67.61% vs. 67.61%) was not statistically significant. However, the specificity of the Wells score and Revised Geneva score was significantly lower than that of the SDH score (48.77%, 39.51% vs. 61.73%). CONCLUSIONS Our logistic regression model and the SDH score based on 7 risk factors as right lower extremity, bilateral lower extremities, unprovoked, surgery or immobilization, malignant tumor, history of VTE, and D-dimer>1,000 ng/mL showed good calibration and discriminative power for the assessment of PE risk in patients with LDVT. The SDH score is more specific for PE prediction in the Chinese population, compared with the Wells score and the Revised Geneva score.
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Affiliation(s)
- Binliang Zhao
- Department of Vascular Surgery, The Affiliated Da Yi Hospital of Shanxi Medical University, China
| | - Bin Hao
- Department of Vascular Surgery, The Affiliated Da Yi Hospital of Shanxi Medical University, China
| | - Huimin Xu
- Department of Vascular Surgery, The Affiliated Da Yi Hospital of Shanxi Medical University, China
| | - Shyamal Premaratne
- Hunter Holmes McGuire Veterans Administration Medical Center, Richmond, VA
| | - Jiantao Zhang
- Department of Vascular Surgery, The Affiliated Da Yi Hospital of Shanxi Medical University, China
| | - Le Jiao
- Department of Vascular Surgery, The Affiliated Da Yi Hospital of Shanxi Medical University, China
| | - Wenpei Zhang
- Department of Vascular Surgery, The Affiliated Da Yi Hospital of Shanxi Medical University, China
| | - Shengquan Wang
- Department of Vascular Surgery, The Affiliated Da Yi Hospital of Shanxi Medical University, China
| | - Xudong Su
- Department of Vascular Surgery, The Affiliated Da Yi Hospital of Shanxi Medical University, China
| | - Lei Sun
- Department of Vascular Surgery, The Affiliated Da Yi Hospital of Shanxi Medical University, China
| | - Jie Yao
- Department of Vascular Surgery, The Affiliated Da Yi Hospital of Shanxi Medical University, China
| | - Ying Yu
- Department of Vascular Surgery, The Affiliated Da Yi Hospital of Shanxi Medical University, China
| | - Tao Yang
- Department of Vascular Surgery, The Affiliated Da Yi Hospital of Shanxi Medical University, China.
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Harder EM, Desai O, Marshall PS. Clinical Probability Tools for Deep Venous Thrombosis, Pulmonary Embolism, and Bleeding. Clin Chest Med 2019; 39:473-482. [PMID: 30122172 DOI: 10.1016/j.ccm.2018.04.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Overdiagnosis of venous thromboembolism is associated with increasing numbers of patient complications and health care burden. Multiple clinical tools exist to estimate the probability of pulmonary embolism and deep venous thrombosis. When used with d-dimer testing, these can further stratify venous thromboembolism risk to help inform the use of additional diagnostic testing. Although there are similar tools to estimate bleeding risk, these are not as well-validated and lack reliability.
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Affiliation(s)
- Eileen M Harder
- Department of Internal Medicine, Yale University School of Medicine, 15 York Street, LCI 101, New Haven, CT 06520, USA
| | - Omkar Desai
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Yale University School of Medicine, 15 York Street, LCI 101, New Haven, CT 06520, USA
| | - Peter S Marshall
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Yale University School of Medicine, 15 York Street, LCI 101, New Haven, CT 06520, USA.
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Sickle cell disease and venous thromboembolism: A retrospective comparison of the rate of positive CT pulmonary angiography in the emergency department. Eur J Radiol 2019; 110:256-259. [PMID: 30599869 DOI: 10.1016/j.ejrad.2018.11.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 11/19/2018] [Accepted: 11/27/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND Previous authors have reported an increased incidence of acute pulmonary embolism (PE) in patients with sickle cell disease (SCD) based on retrospective analysis of ICD codes. It is unknown whether patients with SCD have higher rates of positive CT pulmonary angiogram (CTPA) in the emergency department (ED). METHODS The institutional review board (IRB) approved this retrospective study; informed consent was waived. Between January 1, 2005 and May 31, 2015, 28 patients with SCD underwent a total of 78 CTPA studies in the ED. A control group of 75 non-SCD patients matched for age, gender and race underwent 78 consecutive CTPA studies in the emergency department. Modified Wells' (mWells') scores were calculated for each CTPA study performed. The studies for both groups were blind read by two fellowship trained body radiologists. Descriptive statistics were performed, with significance considered if p < 0.05. RESULTS The rate of positive CT pulmonary angiogram in patients with SCD was 6.4% (5/78), compared with 12.8% (10/78) in non-SCD matched controls. There was no significant difference in the rate of positive CTPA (p = 0.277). There was also no difference in the mean mWells' score between the two groups (2.44 for SCD vs. 1.95 for controls, p = 0.120). CONCLUSION SCD patients did not have a significantly different rate of acute PE when compared with matched controls undergoing CTPA in the ED.
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Lipinska A, Ledakowicz-Polak A, Krauza G, Przybylak K, Zielinska M. Complex calculation or quick glance? Mean platelet volume - new predictive marker for pulmonary embolism. Ther Clin Risk Manag 2018; 14:2221-2228. [PMID: 30519030 PMCID: PMC6233702 DOI: 10.2147/tcrm.s181381] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Wells and Geneva scores are widely used in the assessment of pretest probability of pulmonary embolism (PE). OBJECTIVE The objective of this study was to examine the hypothesis that mean platelet volume (MPV) may better predict PE than the clinical prediction rules. METHODS A study was performed among patients with PE. Baseline characteristics and complete blood counts including MPV were prospectively recorded upon admission. To assess clinical probability in patients with PE risk, we used Wells and Geneva scores. RESULTS Data records of 136 patients (males: 44%) with median age of 66 years (interquartile range [IQR] 57.5-78.0) diagnosed with PE at the Intensive Cardiac Therapy Clinic in Lodz (Poland) were analyzed. Baseline characteristics indicate that patients suffered from arterial hypertension (65%), obesity (32%), and diabetes mellitus (24%). Furthermore, they reported active smoking (21%), prolonged immobilization (20%), major surgery (21%), pregnancy (4%), and oral contraceptives (9%). Patients presented with various symptoms. The MPV, plateletcrit, and D-dimer values on admission were respectively as follows: 10.71 (IQR 3.29-13.67), 0.2 (IQR 0.15-0.24), and 9.23 (IQR 8.5-9.85). The study revealed that Wells score correlated significantly with an elevated MPV value (P<0.05) per contra to Geneva score (P>0.05). According to our results, there is a lack of coherence between Wells and Geneva scores (P>0.05). Finally, we determined that the optimum MPV level cutoff point for PE on admission with reference to the original Wells score is 9.6 fL. CONCLUSION MPV may be considered useful as an adjunctive or independent predictive marker for PE used in lieu of clinical prediction rules.
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Affiliation(s)
- Anna Lipinska
- Intensive Cardiac Therapy Clinic, Department of Interventional Cardiology and Electrocardiology, Central Clinical Hospital, Lodz, Poland,
| | - Anna Ledakowicz-Polak
- Intensive Cardiac Therapy Clinic, Department of Interventional Cardiology and Electrocardiology, Central Clinical Hospital, Lodz, Poland,
| | - Grzegorz Krauza
- Intensive Cardiac Therapy Clinic, Department of Interventional Cardiology and Electrocardiology, Central Clinical Hospital, Lodz, Poland,
| | - Katarzyna Przybylak
- Intensive Cardiac Therapy Clinic, Department of Interventional Cardiology and Electrocardiology, Central Clinical Hospital, Lodz, Poland,
| | - Marzenna Zielinska
- Intensive Cardiac Therapy Clinic, Department of Interventional Cardiology and Electrocardiology, Central Clinical Hospital, Lodz, Poland,
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Touhami O, Marzouk SB, Bennasr L, Touaibia M, Souli I, Felfel MA, Kehila M, Channoufi MB, Magherbi HE. Are the Wells Score and the Revised Geneva Score valuable for the diagnosis of pulmonary embolism in pregnancy? Eur J Obstet Gynecol Reprod Biol 2017; 221:166-171. [PMID: 29310042 DOI: 10.1016/j.ejogrb.2017.12.049] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Accepted: 12/28/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To evaluate and to compare the predictive accuracy of the Wells score and the revised Geneva scores for the diagnosis of pulmonary embolism in the pregnant and postpartum population. STUDY DESIGN All pregnant or post-partum patients with a suspected PE and for whom a diagnostic imaging testing was performed (VQ scintigraphy or computed tomography pulmonary angiography) over a 3-year period were included in the study. The Wells and Revised Geneva Scores were calculated on the same cohort of patients and dichotomized into low and intermediate/high probability groups. The sensitivities and specificities were calculated. Overall accuracy was determined using receiver operator characteristic curve analysis. RESULTS A total of 103 patients were included. The overall prevalence of PE was 26.2% (27/103). Using the Wells Score, the prevalence of patients with PE in the low, intermediate and high probability categories was 20.5%, 43.5% and 50% respectively. Using the Revised Geneva Score, the prevalence of patients with PE in the low, intermediate and high probability categories was 17%, 36.2 and 33.3% respectively. In low risk groups of the Wells score and the simplified revised Geneva score the prevalence of PE was not statistically significantly different: respectively: 20.5% and 17.5% (p = 0,232). The agreement on clinical assessment using the Wells score and using the revised Geneva score was weak (κ coefficient = 0.154). In total, 26 (25.2%) patients were classified differently using the 2 scores. There was no significant difference in the overall accuracies of the Wells (0.67, 95% CI 0.54-0.79) and Revised Geneva Scores (0.64, 95% CI 0.52-0.76) as determined by the area under the ROC curves (P = 0.628). The sensitivity, specificity, PPV and NPV of the Wells score and the revised Geneva score were respectively: 40.7%, 81.5%, 44%, 79.4% and 62.9%, 59.2%, 35.4%, 81.8%. CONCLUSION(S) The Wells score and the revised Geneva seems not to be valuable in the pregnant and post partum population. A specific risk score of PE for pregnant and postpartum population is needed to reduce the rate of unnecessary imaging studies, especially in this specific population were the use of radiation and contrast agent is problematic.
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Affiliation(s)
- Omar Touhami
- "C" Department of Obstetrics and Gynecology, Tunis Maternity and Neonatology Center, Tunis El Manar University, Tunisia.
| | - Sofiene Ben Marzouk
- Anesthesiology and Reanimation Department, Tunis Maternity and Neonatology Center, Tunis El Manar University, Tunisia
| | - Laidi Bennasr
- Anesthesiology and Reanimation Department, Tunis Maternity and Neonatology Center, Tunis El Manar University, Tunisia
| | - Maha Touaibia
- Anesthesiology and Reanimation Department, Tunis Maternity and Neonatology Center, Tunis El Manar University, Tunisia
| | - Iheb Souli
- Anesthesiology and Reanimation Department, Tunis Maternity and Neonatology Center, Tunis El Manar University, Tunisia
| | - Mohamed Amine Felfel
- Anesthesiology and Reanimation Department, Tunis Maternity and Neonatology Center, Tunis El Manar University, Tunisia
| | - Mehdi Kehila
- "C" Department of Obstetrics and Gynecology, Tunis Maternity and Neonatology Center, Tunis El Manar University, Tunisia
| | - Mohamed Badis Channoufi
- "C" Department of Obstetrics and Gynecology, Tunis Maternity and Neonatology Center, Tunis El Manar University, Tunisia
| | - Hayen El Magherbi
- Anesthesiology and Reanimation Department, Tunis Maternity and Neonatology Center, Tunis El Manar University, Tunisia
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Harringa JB, Bracken RL, Nagle SK, Schiebler ML, Pulia MS, Svenson JE, Repplinger MD. Negative D-dimer testing excludes pulmonary embolism in non-high risk patients in the emergency department. Emerg Radiol 2017; 24:273-280. [PMID: 28116533 PMCID: PMC5438894 DOI: 10.1007/s10140-017-1478-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Accepted: 01/06/2017] [Indexed: 01/08/2023]
Abstract
PURPOSE The purpose of this study was to assess the ability of d-dimer testing to obviate the need for cross-sectional imaging for patients at "non-high risk" for pulmonary embolism (PE). METHODS This is a retrospective study of emergency department patients at an academic medical center who underwent cross-sectional imaging (MRA or CTA) to evaluate for PE from 2008 to 2013. The primary outcome was the NPV of d-dimer testing when used in conjunction with clinical decision instruments (CDIs = Wells', Revised Geneva, and Simplified Revised Geneva Scores). The reference standard for PE status included image test results and a 6-month chart review follow-up for venous thromboembolism as a proxy for false negative imaging. Secondary analyses included ROC curves for each CDI and calculation of PE prevalence in each risk stratum. RESULTS Of 459 patients, 41 (8.9%) had PE. None of the 76 patients (16.6%) with negative d-dimer results had PE. Thus, d-dimer testing had 100% sensitivity and NPV, and there were no differences in CDI performance. Similarly, when evaluated independently of d-dimer results, no CDI outperformed the others (areas under the ROC curves ranged 0.53-0.55). There was a significantly higher PE prevalence in the high versus "non-high risk" groups when stratified by the Wells' Score (p = 0.03). CONCLUSIONS Negative d-dimer testing excluded PE in our retrospective cohort. Each CDI had similar NPVs, whether analyzed in conjunction with or independently of d-dimer results. Our results confirm that PE can be safely excluded in patients with "non-high risk" CDI scores and a negative d-dimer.
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Affiliation(s)
- John B Harringa
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, 800 University Bay Drive, Suite 310, Mail Code 9123, Madison, WI, 53705, USA
| | - Rebecca L Bracken
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, 800 University Bay Drive, Suite 310, Mail Code 9123, Madison, WI, 53705, USA
| | - Scott K Nagle
- Department of Radiology, University of Wisconsin-Madison, Madison, USA
| | - Mark L Schiebler
- Department of Radiology, University of Wisconsin-Madison, Madison, USA
| | - Michael S Pulia
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, 800 University Bay Drive, Suite 310, Mail Code 9123, Madison, WI, 53705, USA
| | - James E Svenson
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, 800 University Bay Drive, Suite 310, Mail Code 9123, Madison, WI, 53705, USA
| | - Michael D Repplinger
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, 800 University Bay Drive, Suite 310, Mail Code 9123, Madison, WI, 53705, USA.
- Department of Radiology, University of Wisconsin-Madison, Madison, USA.
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15
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Algoritmo para el diagnóstico y el seguimiento de la tromboembolia pulmonar aguda. RADIOLOGIA 2017; 59:75-87. [DOI: 10.1016/j.rx.2016.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 10/04/2016] [Accepted: 10/26/2016] [Indexed: 01/24/2023]
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Shen JH, Chen HL, Chen JR, Xing JL, Gu P, Zhu BF. Comparison of the Wells score with the revised Geneva score for assessing suspected pulmonary embolism: a systematic review and meta-analysis. J Thromb Thrombolysis 2016; 41:482-92. [PMID: 26178041 DOI: 10.1007/s11239-015-1250-2] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The Wells score and the revised Geneva score are two most commonly used clinical rules for excluding pulmonary embolism (PE). In this study, we aimed to assess the diagnostic accuracy of these two rules; we also compared the diagnostic accuracy between them. We searched PubMed and Web of science up to April 2015. Studies assessed Wells score and revised Geneva score for diagnosis suspected PE were included. The summary area under the curve (AUC) and the 95 % confidence interval (CI) were calculated. Eleven studies were included in this meta-analysis. For Wells score, the sensitivity ranged from 63.8 to 79.3 %, and the specificity ranged from 48.8 to 90.0 %. The overall weighted AUC was 0.778 (95 % CI 0.740-0.818; Z = 9.88, P < 0.001). For revised Geneva score, the sensitivity ranged from 55.3 to 73.6 %. The overall weighted AUC was 0.693 (95 % CI 0.653-0.736; Z = 11.96, P < 0.001). 95 % CIs of two AUCs were not overlapped, which indicated Wells score was more accurate than revised Geneva score for predicting PE in suspected patients. Meta-regression showed diagnostic accuracy of these two rules was not related with PE prevalence. Sensitivity analysis by only included prospective studies showed the results were robust. Our results showed the Wells score was more effective than the revised Geneva score in discriminate PE in suspected patients.
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Affiliation(s)
- Jun-Hua Shen
- Department of Emergency, Nantong First People's Hospital, North Haierxiang Road 6#, Nantong, 226001, Jiangsu, People's Republic of China
| | - Hong-Lin Chen
- Nantong University, Nantong, People's Republic of China
| | - Jian-Rong Chen
- Department of Emergency, Nantong First People's Hospital, North Haierxiang Road 6#, Nantong, 226001, Jiangsu, People's Republic of China
| | - Jia-Li Xing
- Department of Emergency, Nantong First People's Hospital, North Haierxiang Road 6#, Nantong, 226001, Jiangsu, People's Republic of China
| | - Peng Gu
- Department of Emergency, Nantong First People's Hospital, North Haierxiang Road 6#, Nantong, 226001, Jiangsu, People's Republic of China
| | - Bao-Feng Zhu
- Department of Emergency, Nantong First People's Hospital, North Haierxiang Road 6#, Nantong, 226001, Jiangsu, People's Republic of China.
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Ma Y, Huang J, Wang Y, Wu T, Cai D, Liu Y, Wu Q, Hui J, Shi Y. Comparison of the Wells score with the revised Geneva score for assessing pretest probability of pulmonary embolism in hospitalized elderly patients. Eur J Intern Med 2016; 36:e18-e19. [PMID: 27650507 DOI: 10.1016/j.ejim.2016.09.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 09/07/2016] [Accepted: 09/07/2016] [Indexed: 01/09/2023]
Affiliation(s)
- Yuxia Ma
- Department of Internal Medicine, Cangzhou Central Hospital, Cangzhou, China.
| | - Jiale Huang
- Department of Cardiology, East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yuliang Wang
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Tongwei Wu
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Danxian Cai
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yanna Liu
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qijing Wu
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jialiang Hui
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yan Shi
- Department of Emergency, The Affiliated Huai'an Hospital of Xuzhou Medical University, Huai'an, China; Department of Emergency, The Second People's Hospital of Huai'an, Huai'an, China.
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Mandatory Assignment of Modified Wells Score Before CT Angiography for Pulmonary Embolism Fails to Improve Utilization or Percentage of Positive Cases. AJR Am J Roentgenol 2016; 207:442-9. [DOI: 10.2214/ajr.15.15394] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Guo DJ, Zhao C, Zou YD, Huang XH, Hu JM, Guo L. Values of the Wells and revised Geneva scores combined with D-dimer in diagnosing elderly pulmonary embolism patients. Chin Med J (Engl) 2015; 128:1052-7. [PMID: 25881599 PMCID: PMC4832945 DOI: 10.4103/0366-6999.155085] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Pulmonary embolism (PE) can be difficult to diagnose in elderly patients because of the coexistent diseases and the combination of drugs that they have taken. We aimed to compare the clinical diagnostic values of the Wells score, the revised Geneva score and each of them combined with D-dimer for suspected PE in elderly patients. METHODS Three hundred and thirty-six patients who were admitted for suspected PE were enrolled retrospectively and divided into two groups based on age (≥65 or <65 years old). The Wells and revised Geneva scores were applied to evaluate the clinical probability of PE, and the positive predictive values of both scores were calculated using computed tomography pulmonary arteriography as a gold standard; overall accuracy was evaluated by the area under the curve (AUC) of receiver operator characteristic curve; the negative predictive values of D-dimer, the Wells score combined with D-dimer, and the revised Geneva score combined with D-dimer were calculated. RESULTS Ninety-six cases (28.6%) were definitely diagnosed as PE among 336 cases, among them 56 cases (58.3%) were ≥65 years old. The positive predictive values of Wells and revised Geneva scores were 65.8% and 32.4%, respectively (P < 0.05) in the elderly patients; the AUC for the Wells score and the revised Geneva score in elderly was 0.682 (95% confidence interval [CI]: 0.612-0.746) and 0.655 (95% CI: 0.584-0.722), respectively (P = 0.389). The negative predictive values of D-dimer, the Wells score combined with D-dimer, and the revised Geneva score combined with D-dimer were 93.7%, 100%, and 100% in the elderly, respectively. CONCLUSIONS The diagnostic value of the Wells score was higher than the revised Geneva score for the elderly cases with suspected PE. The combination of either the Wells score or the revised Geneva score with a normal D-dimer concentration is a safe strategy to rule out PE.
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Affiliation(s)
- Dan-Jie Guo
- Department of Cardiology, Peking University People's Hospital, Beijing 100044, China
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20
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Ostovan MA, Ghaffari S, Pourafkari L, Dehghani P, Hajizadeh R, Nadiri M, Ghaffari MR. Modification of Simplified Pulmonary Embolism Severity Index and its Prognostic Value in Patients with Acute Pulmonary Embolism. Heart Lung Circ 2015; 25:184-90. [PMID: 26481399 DOI: 10.1016/j.hlc.2015.08.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 07/16/2015] [Accepted: 08/17/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Various risk stratification systems have been used to predict the clinical outcome of patients with pulmonary embolism (PE). In this study we present a modification of the simplified Pulmonary Embolism Severity Index (S-PESI) score and evaluate its accuracy in predicting the outcome of these patients. MATERIALS AND METHODS Patients older than 18 years with documented PE were enrolled in this study. S-PESI was calculated in all patients. We added electrocardiographic evidence of right ventricular strain as a new criteria and replaced the O2 saturation of <90% in S-PESI score with PaO2 /PaCO2 ratio obtained from the arterial blood gas analysis as two newly modified criteria to define a modified form of S-PESI system (modified s-PESI). Patients were followed for about one year in outpatient clinics. Any deaths attributable to PE or for unknown reasons were considered as PE related. We defined Major Adverse Cardio-Pulmonary Events (MACPE) as sum of one-year mortality, need for thrombolysis and mechanical ventilation during index hospitalisation. RESULTS Among 300 enrolled patients, in-hospital mortality occurred in 38 (12.7%) and one-year mortality in 73 (24.3%) patients. Considering a cut-off point of 3, modified s-PESI score had a lower sensitivity (49.3% vs. 89%) and higher specificity (79.4% vs. 37.7%) than S-PESI to predict one-year mortality. Area Under Curve (AUC) to predict MACPE was significantly higher for modified s-PESI (0.692 vs 0.730, P=0.012). CONCLUSION The modified s-PESI is superior to S-PESI in predicting one-year outcome in patients with PE and can be used for more accurate risk stratification of these patients.
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Affiliation(s)
| | - Samad Ghaffari
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.
| | - Leili Pourafkari
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Pooyan Dehghani
- Cardiology Department, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Reza Hajizadeh
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mehdi Nadiri
- Pulmonology Department, Imam Reza Hospital, Tabriz, Iran
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Post F, Gori T, Giannitsis E, Darius H, Baldus S, Hamm C, Hambrecht R, Hofmeister HM, Katus H, Perings S, Senges J, Münzel T. Criteria of the German Society of Cardiology for the establishment of chest pain units: update 2014. Clin Res Cardiol 2015; 104:918-28. [PMID: 26150114 PMCID: PMC4623090 DOI: 10.1007/s00392-015-0888-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 06/23/2015] [Indexed: 12/22/2022]
Abstract
Since 2008, the German Cardiac Society (DGK) has been establishing a network of certified chest pain units (CPUs). The goal of CPUs was and is to carry out differential diagnostics of acute or newly occurring chest pain of undetermined origin in a rapid and goal-oriented manner and to take immediate therapeutic measures. The basis for the previous certification process was criteria that have been established and published by the task force on CPUs. These criteria regulate the spatial and technical requirements and determine diagnostic and therapeutic strategies in patients with chest pain. Furthermore, the requirements for the organization of CPUs and the training requirements for the staff of a CPU are defined. The certification process is carried out by the DGK; currently, 225 CPUs are certified and 139 CPUs have been recertified after running for a period of 3 years. The certification criteria have now been revised and updated according to new guidelines.
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Affiliation(s)
- Felix Post
- Katholisches Klinikum Koblenz Montabaur, Koblenz, Germany
| | - Tommaso Gori
- II. Medizinische Klinik und Poliklinik für Kardiologie, Angiologie und internistische Intensivmedizin, Universitätsmedizin Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | | | - Harald Darius
- Department für Kardiologie, Innere Medizin und Intensivmedizin, Vivantes-Klinikum Neukölln, Berlin, Germany
| | - Stephan Baldus
- Klinikum III für Innere Medizin Uniklinik Köln, Cologne, Germany
| | | | - Rainer Hambrecht
- Klinik für Kardiologie und Angiologie, Herzzentrum Bremen, Bremen, Germany
| | | | - Hugo Katus
- Klinik für KardiologieAngiologie und Pneumonologie, Heidelberg, Germany
| | | | - Jochen Senges
- Institut für Herzinfarktforschung, Ludwigshafen, Germany
| | - Thomas Münzel
- II. Medizinische Klinik und Poliklinik für Kardiologie, Angiologie und internistische Intensivmedizin, Universitätsmedizin Mainz, Langenbeckstr. 1, 55131, Mainz, Germany.
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Di Marca S, Cilia C, Campagna A, D'Arrigo G, Abd ElHafeez S, Tripepi G, Puccia G, Pisano M, Mastrosimone G, Terranova V, Cardella A, Buonacera A, Stancanelli B, Zoccali C, Malatino L. Comparison of Wells and Revised Geneva Rule to Assess Pretest Probability of Pulmonary Embolism in High-Risk Hospitalized Elderly Adults. J Am Geriatr Soc 2015; 63:1091-7. [PMID: 26032745 DOI: 10.1111/jgs.13459] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVES To assess and compare the diagnostic power for pulmonary embolism (PE) of Wells and revised Geneva scores in two independent cohorts (training and validation groups) of elderly adults hospitalized in a non-emergency department. DESIGN Prospective clinical study, January 2011 to January 2013. SETTING Unit of Internal Medicine inpatients, University of Catania, Italy. PARTICIPANTS Elderly adults (mean age 76 ± 12), presenting with dyspnea or chest pain and with high clinical probability of PE or D-dimer values greater than 500 ng/mL (N = 203), were enrolled and consecutively assigned to a training (n = 101) or a validation (n = 102) group. The clinical probability of PE was assessed using Wells and revised Geneva scores. MEASUREMENTS Clinical examination, D-dimer test, and multidetector computed angiotomography were performed in all participants. The accuracy of the scores was assessed using receiver operating characteristic analyses. RESULTS PE was confirmed in 46 participants (23%) (24 training group, 22 validation group). In the training group, the area under the receiver operating characteristic curve was 0.91 (95% confidence interval (CI) = 0.85-0.98) for the Wells score and 0.69 (95% CI = 0.56-0.82) for the revised Geneva score (P < .001). These results were confirmed in the validation group (P < .05). The positive (LR+) and negative likelihood ratios (LR-) (two indices combining sensitivity and specificity) of the Wells score were superior to those of the revised Geneva score in the training (LR+, 7.90 vs 1.34; LR-, 0.23 vs 0.66) and validation (LR+, 13.5 vs 1.46; LR-, 0.47 vs 0.54) groups. CONCLUSION In high-risk elderly hospitalized adults, the Wells score is more accurate than the revised Geneva score for diagnosing PE.
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Affiliation(s)
- Salvatore Di Marca
- Unit of Internal Medicine, Department of Clinical and Experimental Medicine, Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Chiara Cilia
- Unit of Internal Medicine, Department of Clinical and Experimental Medicine, Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Andrea Campagna
- Unit of Internal Medicine, Department of Clinical and Experimental Medicine, Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Graziella D'Arrigo
- Unit of Statistics, National Research Council, Institute of Clinical Physiology, Institute of Biomedicine and Molecular Immunology, Ospedali Riuniti, Reggio Calabria, Italy
| | - Samar Abd ElHafeez
- Unit of Statistics, National Research Council, Institute of Clinical Physiology, Institute of Biomedicine and Molecular Immunology, Ospedali Riuniti, Reggio Calabria, Italy.,Epidemiology Department, High Institute of Public Health, Alexandria University, Alexandria, Egypt
| | - Giovanni Tripepi
- Unit of Statistics, National Research Council, Institute of Clinical Physiology, Institute of Biomedicine and Molecular Immunology, Ospedali Riuniti, Reggio Calabria, Italy
| | - Giuseppe Puccia
- Unit of Internal Medicine, Department of Clinical and Experimental Medicine, Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Marcella Pisano
- Unit of Internal Medicine, Department of Clinical and Experimental Medicine, Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Gianluca Mastrosimone
- Unit of Internal Medicine, Department of Clinical and Experimental Medicine, Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Valentina Terranova
- Unit of Internal Medicine, Department of Clinical and Experimental Medicine, Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Antonella Cardella
- Unit of Internal Medicine, Department of Clinical and Experimental Medicine, Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Agata Buonacera
- Unit of Internal Medicine, Department of Clinical and Experimental Medicine, Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Benedetta Stancanelli
- Unit of Internal Medicine, Department of Clinical and Experimental Medicine, Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Carmine Zoccali
- Unit of Statistics, National Research Council, Institute of Clinical Physiology, Institute of Biomedicine and Molecular Immunology, Ospedali Riuniti, Reggio Calabria, Italy
| | - Lorenzo Malatino
- Unit of Internal Medicine, Department of Clinical and Experimental Medicine, Cannizzaro Hospital, University of Catania, Catania, Italy
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Levin D, Seo JB, Kiely DG, Hatabu H, Gefter W, van Beek EJR, Schiebler ML. Triage for suspected acute Pulmonary Embolism: Think before opening Pandora's Box. Eur J Radiol 2015; 84:1202-11. [PMID: 25864020 DOI: 10.1016/j.ejrad.2015.03.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Revised: 02/26/2015] [Accepted: 03/23/2015] [Indexed: 12/22/2022]
Abstract
This is a review of the current strengths and weaknesses of the various imaging modalities available for the diagnosis of suspected non-massive Pulmonary Embolism (PE). Without careful consideration for the clinical presentation, and the timely application of clinical decision support (CDS) methodology, the current overutilization of imaging resources for this disease will continue. For a patient with a low clinical risk profile and a negative D-dimer there is no reason to consider further workup with imaging; as the negative predictive value in this scenario is the same as imaging. While the current efficacy and effectiveness data support the continued use of Computed Tomographic angiography (CTA) as the imaging golden standard for the diagnosis of PE; this test does have the unintended consequences of radiation exposure, possible overdiagnosis and overuse. There is a persistent lack of appreciation on the part of ordering physicians for the effectiveness of the alternatives to CTA (ventilation-perfusion imaging and contrast enhanced magnetic resonance angiography) in these patients. Careful use of standardized protocols for patient triage and the application of CDS will allow for a better use of imaging resources.
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Affiliation(s)
- David Levin
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Joon Beom Seo
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, M-15, M-Floor, Royal Hallamshire Hospital, Sheffield, UK
| | - Hiroto Hatabu
- Department of Radiology, Brigham and Women's Hospital and Harvard Medical School Boston, MA, USA
| | - Warren Gefter
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | | | - Mark L Schiebler
- Department of Radiology, UW-Madison School of Medicine and Public Health, 600 Highland Avenue, Madison, WI 53792-3252, USA.
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Kriterien der Deutschen Gesellschaft für Kardiologie – Herz- und Kreislaufforschung für „Chest Pain Units“. KARDIOLOGE 2015. [DOI: 10.1007/s12181-014-0646-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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25
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Diagnostic de l’embolie pulmonaire au service des urgences. MEDECINE INTENSIVE REANIMATION 2013. [DOI: 10.1007/s13546-013-0730-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Sarazin M, Chiappe SG, Kasprzyk M, Mismetti P, Lasserre A. A survey of French general practitioners and a qualitative study on their use and assessment of predictive clinical scores. Int J Gen Med 2013; 6:419-26. [PMID: 23837004 PMCID: PMC3699135 DOI: 10.2147/ijgm.s39022] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Predictive clinical scores, diagnostic as well as prognostic, are considered to be useful tools for making decisions under conditions of uncertainty. They are not intended to replace clinical judgment or medical experience, but to help physicians in the interpretation of clinical information. The general practitioner (GP), the gateway to care in the French health system, should be the main beneficiary of their utilization. However, there is no information on the prevalence of their use in general practice in France. METHODS A national, transversal epidemiological survey was conducted by electronic mail among GPs belonging to the French Sentinelles network. GPs were asked about their use of scores, the context of their utilization and the expected benefit. A qualitative study (focus groups) was also carried out with three groups of GPs within the context of continuous medical education. RESULTS The study consisted of 358 GPs. They were questioned on their use of seven predictive clinical scores (six diagnostic and one prognostic). Clinical scores were used by 75% of GPs, with no statistical difference with regard to their age or sex. The most often used were: the Mini Mental Status Examination (MMSE) (95%), Fagerström test (90%), Hamilton scale (65%), McIsaac scores (61%), DETA/CAGE (45%), Simple Calculated Osteoporosis Risk Estimation (SCORE) for osteoporosis (33%), and the only prognostic score CHADS2 (28%). Clinical scores were especially used when elderly people were involved (77%) and when the diagnosis was uncertain (63%). The qualitative study gave additional information on the barriers and obstacles to the use of predictive clinical scores. CONCLUSION This study, the first one in France, gives information on the perception of clinical scores and on the rationale for their use by GPs. Suggestions to improve the situation (availability and rate of utilization of clinical scores) are provided.
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Affiliation(s)
- Marianne Sarazin
- Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France
- Centre Hospitalier, Firminy, France
| | - Solange Gonzalez Chiappe
- Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France
- Centre Hospitalier, Firminy, France
| | - Marie Kasprzyk
- Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France
| | | | - Andréa Lasserre
- Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France
- UPMC University Paris, Paris, France
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Expedited Management of Deep Vein Thrombosis and Acute Pulmonary Embolism. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2013. [DOI: 10.1007/s40138-013-0015-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Penaloza A, Verschuren F, Meyer G, Quentin-Georget S, Soulie C, Thys F, Roy PM. Comparison of the unstructured clinician gestalt, the wells score, and the revised Geneva score to estimate pretest probability for suspected pulmonary embolism. Ann Emerg Med 2013; 62:117-124.e2. [PMID: 23433653 DOI: 10.1016/j.annemergmed.2012.11.002] [Citation(s) in RCA: 115] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2012] [Revised: 10/27/2012] [Accepted: 11/02/2012] [Indexed: 01/02/2023]
Abstract
STUDY OBJECTIVE The assessment of clinical probability (as low, moderate, or high) with clinical decision rules has become a cornerstone of diagnostic strategy for patients with suspected pulmonary embolism, but little is known about the use of physician gestalt assessment of clinical probability. We evaluate the performance of gestalt assessment for diagnosing pulmonary embolism. METHODS We conducted a retrospective analysis of a prospective observational cohort of consecutive suspected pulmonary embolism patients in emergency departments. Accuracy of gestalt assessment was compared with the Wells score and the revised Geneva score by the area under the curve (AUC) of receiver operating characteristic curves. Agreement between the 3 methods was determined by κ test. RESULTS The study population was 1,038 patients, with a pulmonary embolism prevalence of 31.3%. AUC differed significantly between the 3 methods and was 0.81 (95% confidence interval [CI] 0.78 to 0.84) for gestalt assessment, 0.71 (95% CI 0.68 to 0.75) for Wells, and 0.66 (95% CI 0.63 to 0.70) for the revised Geneva score. The proportion of patients categorized as having low clinical probability was statistically higher with gestalt than with revised Geneva score (43% versus 26%; 95% CI for the difference of 17%=13% to 21%). Proportion of patients categorized as having high clinical probability was higher with gestalt than with Wells (24% versus 7%; 95% CI for the difference of 17%=14% to 20%) or revised Geneva score (24% versus 10%; 95% CI for the difference of 15%=13% to 21%). Pulmonary embolism prevalence was significantly lower with gestalt versus clinical decision rules in low clinical probability (7.6% for gestalt versus 13.0% for revised Geneva score and 12.6% for Wells score) and non-high clinical probability groups (18.3% for gestalt versus 29.3% for Wells and 27.4% for revised Geneva score) and was significantly higher with gestalt versus Wells score in high clinical probability groups (72.1% versus 58.1%). Agreement between the 3 methods was poor, with all κ values below 0.3. CONCLUSION In our retrospective study, gestalt assessment seems to perform better than clinical decision rules because of better selection of patients with low and high clinical probability.
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Affiliation(s)
- Andrea Penaloza
- Emergency Department, Cliniques Universitaires St-Luc, Université Catholique de Louvain, Belgium.
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Wells P, Anderson D. The diagnosis and treatment of venous thromboembolism. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2013; 2013:457-463. [PMID: 24319219 DOI: 10.1182/asheducation-2013.1.457] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Venous thromboembolism (VTE) is a common condition that can lead to complications such as postphlebitic syndrome, chronic pulmonary artery hypertension, and death. The approach to the diagnosis of has evolved over the years and an algorithm strategy combining pretest probability, D-dimer testing, and diagnostic imaging now allows for safe, convenient, and cost-effective investigation of patients. Patients with low pretest probability and a negative D-dimer can have VTE excluded without the need for imaging. The mainstay of treatment of VTE is anticoagulation, whereas interventions such as thrombolysis and inferior vena cava filters are reserved for special situations. Low-molecular-weight heparin has allowed for outpatient management of most patients with deep vein thrombosis at a considerable cost savings to the health care system. Patients with malignancy-associated VTE benefit from decreased recurrent rates if treated with long-term low-molecular-weight heparin. The development of new oral anticoagulants further simplifies treatment. The duration of anticoagulation is primarily influenced by underlying cause of the VTE (whether provoked or not) and consideration of the risk for major hemorrhage. Testing for genetic and acquired thrombophilia may provide insight as to the cause of a first idiopathic deep vein thrombosis, but the evidence linking most thrombophilias to an increased risk of recurrent thrombosis is limited.
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Affiliation(s)
- Philip Wells
- 1Department of Medicine, University of Ottawa and the Ottawa Hospital, Ottawa Hospital Research Institute, Ottawa, ON; and
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Komissarova M, Chong S, Frey K, Sundaram B. Imaging of acute pulmonary embolism. Emerg Radiol 2012; 20:89-101. [PMID: 23151968 DOI: 10.1007/s10140-012-1080-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Accepted: 10/01/2012] [Indexed: 12/26/2022]
Abstract
Acute pulmonary thromboembolism (PE) is a cardiovascular emergency associated with significant morbidity and a 5-35 % mortality for untreated pulmonary embolism. If promptly diagnosed and treated, the mortality rate can be significantly reduced. Diagnosis of acute PE continues to be a clinical challenge, with diagnostic imaging playing an important role. This review discusses the clinical challenges of diagnosing acute PE, presents an evidence-based review of the current tests and ever-evolving imaging technology, and highlights special considerations related to radiation dose, contrast media use, and pregnant patients.
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Affiliation(s)
- Maria Komissarova
- Divisions of Emergency, Cardiothoracic and Nuclear Radiology, Department of Radiology, University of Michigan, 1500 E. Medical Center Drive, TC B1-140D, Ann Arbor, MI 48109, USA
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Adams AG, Awsare BK. Review for hospitalists: acute pulmonary embolism. Hosp Pract (1995) 2012; 39:55-62. [PMID: 22056823 DOI: 10.3810/hp.2011.10.922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Acute pulmonary embolism (PE) is a common and potentially life-threatening disease; however, the clinical presentation of acute PE can be quite variable, making the diagnosis a challenge. Occlusion of the pulmonary arterial bed can lead to gas exchange abnormalities or right ventricular dysfunction. Mortality rates are high but can be reduced when prompt suspicion leads to accurate diagnosis and treatment. Management includes timely initiation of anticoagulation therapy. The objective of this article is to provide a broad overview of acute PE epidemiology, risk factors, diagnosis, risk stratification, and management.
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Affiliation(s)
- Andrea G Adams
- Division of Pulmonary Critical Care Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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Moheimani F, Jackson DE. Venous thromboembolism: classification, risk factors, diagnosis, and management. ISRN HEMATOLOGY 2011; 2011:124610. [PMID: 22084692 PMCID: PMC3196154 DOI: 10.5402/2011/124610] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2011] [Accepted: 08/09/2011] [Indexed: 01/13/2023]
Abstract
Venous thromboembolism (VTE) is categorised as deep venous thrombosis (DVT) and pulmonary embolism (PE). VTE is associated with high morbidity and causes a huge financial burden on patients, hospitals, and governments. Both acquired and hereditary risks factors contribute to VTE. To diagnose VTE, noninvasive cost-effective diagnostic algorithms including clinical probability assessment and D-dimer measurement may be employed followup by compression ultrasonography for suspected DVT patients and multidetector computed tomography angiography for suspected PE patients. There are pharmacological and mechanical interventions to manage and prevent VTE. The pharmacological approaches mainly target pathways in coagulation cascade nonspecifically: conventional anticoagulants or specifically: new generation of anticoagulants. Excess bleeding is one of the major risk factors for pharmacological interventions. Hence, nonpharmacological or mechanical approaches such as inferior vena cava filters, graduated compression stockings, and intermittent pneumatic compression devices in combination with pharmacological interventions or alone may be a good approach to manage VTE.
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Affiliation(s)
- Fatemeh Moheimani
- Thrombosis and Vascular Diseases Laboratory, Health Innovations Research Institute and School of Medical Sciences, RMIT University, P.O. Box 71, Bundoora, VIC 3083, Australia
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