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Sharma Y, Sumanadasa S, Shahi R, Horwood C, Thompson C. The value of distinguishing patients with isolated subsegmental pulmonary embolism presenting to two tertiary hospitals in Australia: an observational study. J Thromb Thrombolysis 2023:10.1007/s11239-023-02845-3. [PMID: 37335459 DOI: 10.1007/s11239-023-02845-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/03/2023] [Indexed: 06/21/2023]
Abstract
Isolated-subsegmental-pulmonary-embolism (SSPE) is increasingly diagnosed with the use of computed-tomography-pulmonary-angiogram (CTPA). There remains clinical equipoise for management of SSPE with previous studies not accounting for frailty while determining clinical outcomes. Clinical outcomes among patients with isolated SSPE were compared with those with a more proximal PE after accounting for frailty and other risk-factors. This study included all patients with a positive CTPA for pulmonary embolism (PE) admitted between 2017 and 2021 to two Australian-tertiary-hospitals. Frailty was determined by use of the hospital-frailty-risk-score (HFRS). Competing-risk-analysis and Cox-proportional hazard models determined the cumulative-risk of VTE and mortality within 3 months and 1 year of index PE event after adjustment for frailty and other variables. Of 334 patients with positive CTPA for PE, 111 (33.2%) had isolated-SSPE. The mean (SD) age was 64.3 (17.7) years, 50.9% were males and 9.6% were frail. The risk of recurrent VTE within 3-months (0.9% vs. 1.8%, P = 0.458) and within 1-year of follow-up (2.7% vs. 6.3%, P = 0.126) did not differ significantly between patients with isolated SSPE and those with more proximal PE. After adjusted analyses, the cumulative-incidence of recurrent VTE was not different among patients with isolated SSPE within 1 year of index event [subdistribution-hazard-ratio (HR) 0.84, 95% CI 0.19 to 3.60]. Similarly, mortality within 1 year of index event was also not different between the two groups (aHR 1.72, 95% CI 0.92-3.23). The prevalence of SSPE was 33.2% and even after adjustment for frailty these patients had no different clinical outcomes than those with proximal PE.
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Affiliation(s)
- Yogesh Sharma
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia.
- Department of General Medicine, Division of Medicine, Cardiac & Critical Care, Flinders Medical Centre, Flinders Drive, Bedford Park, Adelaide, SA, 5002, Australia.
| | - Subodha Sumanadasa
- Department of General Medicine, Division of Medicine, Cardiac & Critical Care, Flinders Medical Centre, Flinders Drive, Bedford Park, Adelaide, SA, 5002, Australia
| | - Rashmi Shahi
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Chris Horwood
- Department of Clinical Epidemiology, Flinders Medical Centre, Adelaide, SA, Australia
| | - Campbell Thompson
- Discipline of Medicine, The University of Adelaide, Adelaide, SA, Australia
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Castañer E, Gonzalez A, Andreu M, Lozano C, Gallardo X. Influence of using recommended radiological criteria on MDCT-angiography diagnosis of single isolated subsegmental pulmonary embolism. Eur Radiol 2022; 32:4284-4291. [PMID: 35032211 DOI: 10.1007/s00330-021-08480-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 10/18/2021] [Accepted: 11/23/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We assessed the rate of false-positive diagnoses of MDCT-pulmonary angiography (MDCT-A) in patients with single isolated subsegmental pulmonary embolism (SISSPE). METHODS All patients who underwent MDCT-A between 2006 and 2017 for ruling out acute pulmonary embolism (PE) and received an initial diagnosis of SISSPE were included. The MDCT-A of these patients were reviewed retrospectively by four experienced thoracic radiologists, who applied radiological criteria recommended by the American College of Chest Physicians Antithrombotic Guidelines (ACCP 2016) for the diagnosis of SISSPE. Data extracted from medical records were history of venous thromboembolism (VTE), alternative diagnoses, other diagnostic studies for VTE, anticoagulation, bleeding complications, and VTE over the following 3 months. RESULTS Of 3839 patients undergoing MDCT-A, PE was found in 1021 (26.6%) and SISSPE in 59 (1.5% overall and 5.8% of all patients with PE). An alternative diagnosis to PE was made on the basis of CT in 33 (55.9%) patients. Forty-one (69.5%) patients received anticoagulants, and major life-threatening bleeding complications occurred in 2, with one death. Recurrent PE was not documented in any patient with SISSPE. In the retrospective assessment of the 59 cases of SISSPE, 21 were negative for PE, with a false-positive rate of 35.6% (21/59); so the percentage of SISSPE cases after the revision was 3.7% of all patients with PE; 11 of these 21 patients received anticoagulation. CONCLUSIONS Radiologists should be aware of the high rate of false-positives when making the diagnosis of SISSPE on MDCT-A without using strict diagnostic criteria. Misdiagnosis exposes patients to unnecessary anticoagulation. KEY POINTS • Radiologist should be aware of the high rate of false-positive diagnoses of single isolated subsegmental pulmonary embolism (SISSPE) in MDCT-pulmonary angiography (MDCT-A) performed for ruling out pulmonary embolism. • Misdiagnosis of SISSPE in MDCT-A can be reduced by using strict diagnostic radiological criteria recommended by the American College of Chest Physicians Antithrombotic Guidelines. • Unnecessary anticoagulation therapy with potential severe bleeding complications may result from misdiagnosis of SISSPE.
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Affiliation(s)
- Eva Castañer
- Servei de Diagnòstic per la Imatge, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT), Universitat Autònoma de Barcelona, Parc Taulí 1, 08208, Sabadell, Barcelona, Spain.
| | - Amàlia Gonzalez
- Servei de Diagnòstic per la Imatge, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT), Universitat Autònoma de Barcelona, Parc Taulí 1, 08208, Sabadell, Barcelona, Spain
| | - Marta Andreu
- Servei de Diagnòstic per la Imatge, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT), Universitat Autònoma de Barcelona, Parc Taulí 1, 08208, Sabadell, Barcelona, Spain
| | - Carme Lozano
- Servei de Diagnòstic per la Imatge, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT), Universitat Autònoma de Barcelona, Parc Taulí 1, 08208, Sabadell, Barcelona, Spain
| | - Xavier Gallardo
- Servei de Diagnòstic per la Imatge, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT), Universitat Autònoma de Barcelona, Parc Taulí 1, 08208, Sabadell, Barcelona, Spain
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Verso M, Di Nisio M. Management of venous thromboembolism in cancer patients: Considerations about the clinical practice guideline update of the American society of clinical oncology. Eur J Intern Med 2020; 71:4-7. [PMID: 31732452 DOI: 10.1016/j.ejim.2019.10.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 10/28/2019] [Indexed: 12/11/2022]
Abstract
The American Society of Clinical Oncology (ASCO) recently updated their clinical practice guidelines. The most novel aspect of this update is represented by the introduction of DOACs as pharmacological options both for prophylaxis and treatment of VTE in patients with cancer. The heterogeneity of the cancer population in terms of type and stage of the malignancy, presence of comorbidities, and variability in cancer treatments and prognosis represent the major challenge of managing VTE in patients with cancer. The use of VTE prophylaxis is currently recommended in cancer patients admitted to the hospital for an acute illness or reduced mobility, but no sufficient information is available on the risk of bleeding during thromboprophylaxis. Concerning the thromboprophylaxis in ambulatory cancer patients receiving chemotherapy, further refinement of existing risk models or development of new models are needed for improving risk stratification to identify high-risk cancer patients. The updated ASCO guidelines recommend the use of DOACs (edoxaban and rivaroxaban) for treatment of VTE in patients with cancer. However, Major concerns on "real-life" use of DOACs in patients with cancer are highlighted especially for the bleeding risk in patients with gastrointestinal cancers and the potential drug-drug interactions with specific anticancer therapies. CONCLUSIONS: Uncertainties to the updated ASCO guidelines remain concerning a number of indications on prophylaxis and treatment due to the limited evidence available. These limitations determine the low strength of the recommendations. The ongoing studies will contribute to refine the best management of patients with cancer-associated VTE.
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Affiliation(s)
- Melina Verso
- Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Via Gerardo Dottori 1, Sant' Andrea delle Fratte 06129 Perugia, Italy.
| | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences, University G. D'Annunzio Chieti-Pescara, Chieti, Italy
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Stoller N, Limacher A, Méan M, Baumgartner C, Tritschler T, Righini M, Beer JH, Rodondi N, Aujesky D. Clinical presentation and outcomes in elderly patients with symptomatic isolated subsegmental pulmonary embolism. Thromb Res 2019; 184:24-30. [PMID: 31683107 DOI: 10.1016/j.thromres.2019.10.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 10/05/2019] [Accepted: 10/14/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Data are limited on clinical presentation and outcomes in elderly patients with acute symptomatic isolated subsegmental pulmonary embolism (SSPE). We compared clinical presentation, risk factors, processes of care, and outcomes between elderly patients with SSPE and patients with more proximal pulmonary embolism (PE). METHODS We prospectively followed 578 patients aged ≥65 years with acute symptomatic isolated SSPE or proximal PE in a multicentre Swiss cohort study. We compared quality of life at three months using the PEmb-QoL, and examined the independent association between localization of PE and clinical outcomes (recurrent venous thromboembolism [VTE], overall mortality) using regression models with adjustment for potential confounders. RESULTS Overall, 11% of patients had isolated SSPE. Patients with SSPE were less likely to have a pulse ≥110/min (3% vs. 13%), but more likely to have active cancer (28% vs. 15%) and to receive outpatient care (11% vs. 4%) than patients with proximal PE. Virtually all patients (98%) with SSPE received anticoagulants. Quality of life did not differ between the groups at 3 months. No patient with SSPE vs. seven patients with proximal PE died from the index PE event. No significant difference was observed for the 3-year cumulative incidence of recurrent VTE (7% vs. 12%) and death (29% vs. 20%). After adjustment, SSPE was not associated with a lower risk of clinical outcomes than proximal PE. CONCLUSIONS Clinical presentation and incidences of adverse outcomes did not differ significantly between elderly patients with SSPE or proximal PE, although the power to detect differences might have been limited given the small number of events. Thus, our study does not provide evidence that unselected, elderly patients with SSPE have a more benign clinical course.
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Affiliation(s)
- Nina Stoller
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Andreas Limacher
- Clinical Trials Unit Bern, University of Bern, Bern, Switzerland
| | - Marie Méan
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Division of Internal Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Christine Baumgartner
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Tobias Tritschler
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marc Righini
- Division of Angiology and Haemostasis, Geneva University Hospital, Geneva, Switzerland
| | - Jürg-Hans Beer
- Department of Internal Medicine, Cantonal Hospital of Baden, Baden, Switzerland
| | - Nicolas Rodondi
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Diagnosis and Exclusion of Pulmonary Embolism. Thromb Res 2018; 163:207-220. [DOI: 10.1016/j.thromres.2017.06.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Revised: 05/30/2017] [Accepted: 06/05/2017] [Indexed: 12/21/2022]
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Peiman S, Abbasi M, Allameh SF, Asadi Gharabaghi M, Abtahi H, Safavi E. Subsegmental pulmonary embolism: A narrative review. Thromb Res 2015; 138:55-60. [PMID: 26702485 DOI: 10.1016/j.thromres.2015.12.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Revised: 11/27/2015] [Accepted: 12/08/2015] [Indexed: 12/12/2022]
Abstract
Through the introduction of computed tomography pulmonary angiography (CTPA) for diagnosis of the pulmonary embolism (PE), the high sensitivity of this diagnostic tool led to detecting peripheral filling defects as small as 2-3mm, termed as subsegmental pulmonary embolism (SSPE). However, despite these substantial increases in diagnosis of small pulmonary embolism, there are minimal changes in mortality. Moreover, SSPE patients generally are hemodynamically stable with mild clinical presentation, lower serum level of biomarkers, lower incidence of associated proximal DVTs and less frequent echocardiographic changes compared to the patients with emboli located in more central pulmonary arteries. However, the pros and cons of anticoagulant therapy versus non-treating, monitoring protocol and exact long term outcome of these patients are still unclear. In this article we review existing evidence and provide an overview of what is known about the diagnosis and management of subsegmental pulmonary embolism.
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Affiliation(s)
- Soheil Peiman
- Advanced Thoracic Research Center, Tehran University of Medical Sciences, Tehran, Iran; Department of Internal Medicine, Tehran University of Medical Sciences, Tehran, Iran.
| | - Mehrshad Abbasi
- Department of Nuclear Medicine, Vali-asr Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Farshad Allameh
- Department of Internal Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Hamidreza Abtahi
- Advanced Thoracic Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Enayat Safavi
- Advanced Thoracic Research Center, Tehran University of Medical Sciences, Tehran, Iran
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Emergency Evaluation for Pulmonary Embolism, Part 2: Diagnostic Approach. J Emerg Med 2015; 49:104-17. [DOI: 10.1016/j.jemermed.2014.12.041] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 12/17/2014] [Accepted: 12/21/2014] [Indexed: 12/14/2022]
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Di Nisio M, Lee AYY, Carrier M, Liebman HA, Khorana AA. Diagnosis and treatment of incidental venous thromboembolism in cancer patients: guidance from the SSC of the ISTH. J Thromb Haemost 2015; 13:880-3. [PMID: 25714858 DOI: 10.1111/jth.12883] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 02/19/2015] [Indexed: 11/28/2022]
Affiliation(s)
- M Di Nisio
- Department of Medical, Oral and Biotechnological Sciences, University 'G. D'Annunzio' of Chieti-Pescara, Chieti, Italy; Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands
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Anticoagulating the subsegmental pulmonary embolism in cancer patients: a survey amongst different medical specialties. J Thromb Thrombolysis 2014; 40:37-41. [DOI: 10.1007/s11239-014-1143-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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