Clinically suspected acute pulmonary embolism: a comparison of presentation, radiological features and outcome in patients with and without PE

Thrombosis and thromboembolism: Brighton collaboration case definition and guidelines for data collection, analysis, and presentation of immunization safety data

This is a Brighton Collaboration case definition of thrombosis and thromboembolism to be used in the evaluation of adverse events following immunization, and for epidemiologic studies for the assessment of background incidence or hypothesis testing. The case definition was developed by a group of experts convened by the Coalition for Epidemic Preparedness Innovations (CEPI) in the context of active development of SARS-CoV-2 vaccines. The case definition format of the Brighton Collaboration was followed to develop a consensus definition and defined levels of certainty, after an exhaustive review of the literature and expert consultation. The document underwent peer review by the Brighton Collaboration Network and by selected expert reviewers prior to submission.

Short and long-term mortality in elderly patients with suspected not confirmed pulmonary embolism

INTRODUCTION

Most patients evaluated for suspected pulmonary embolism(PE) conclude the Emergency Department(ED) work-up with a diagnosis of PE not confirmed(PE excluded;PE-E). We aimed to investigate the clinical features, short and long-term mortality, and prognostic factors for death in elderly with PE-E, and to compare these figures with those of patients with PE confirmed(PE-C).

METHODS

Consecutive patients ≥65 years old evaluated in the ED for clinically suspected hemodynamically stable acute PE were included in this retrospective cohort study.

RESULTS

Study population: 657 patients with suspected PE, PE-C:162(24.65%). When compared with PE-C, patients with PE-E presented a higher prevalence of chronic cardiopulmonary disease (17.37% vs 8.02%, p = 0.003), a lower prevalence of pulse rate >110 (13.13% vs 25.93%; p<0.001), of arterial oxygen saturation <90% (16.16% vs. 25.93%; p = 0.007) and of hospitalized patients (52.93% vs 98.15%; p < 0.001). Thirty-day, 90-day, 1-year, 2-year and 5-year overall mortality was 8.83%, 15.98%, 23.59%, 29.68%, and 51.09%, respectively, differences between PE-E and PE-C non statistically significant. Among patients with PE-E, multivariate analysis showed that simplified Pulmonary Embolism Severity Index score>0 was associated with higher short and long-term mortality (30-day:HR:5.31,p = 0.029; 5 year:HR:2.18, p < 0.001), meanwhile comorbidity (Charlson Comorbidity Index>0) only with higher long-term mortality (30-day: HR:1.60, p = 0.342; 5 year: HR:1.41, p = 0.038).

CONCLUSION

In real world haemodinamically stable elderly patients evaluated in the ED for suspected PE, short and long-term mortality was markedly high regardless whether PE was confirmed or excluded. At the time to set management and follow up strategies, elderly patients with PE excluded should not be considered a low-risk population.

Clinical and echocardiographic findings of patients with suspected acute pulmonary thromboembolism who underwent computed tomography pulmonary angiography

Background:

The aim of the study was to determine the correlation between clinical and echocardiographic findings and risk factors of patients with suspected acute pulmonary thromboembolism (PTE) who underwent computed tomography pulmonary angiography (CTPA).

Materials and Methods:

In this cross-sectional study, 310 hospitalized patients aged >18 years with high clinical suspicion of PTE referred to imaging center of our hospital from different wards for CTPA were enrolled. The frequency of different clinical presentations, risk factors, items of Wells’ criteria, and echocardiographic findings was compared in patients with and without PTE, which have been diagnosed according to the CTPA results.

Results:

PTE was diagnosed in 53 (17.1%) of patients with suspected PTE. From clinical manifestations, tachypnea, pleuritic chest pain, and edema of lower extremities were significantly more frequent among patients with PTE (P < 0.05). Major surgery was the risk factor which was significantly more prevalent among patients with PTE (P < 0.05). Frequency of all criteria of Wells’ criteria, except hemoptysis, was significantly higher in patients with PTE (P < 0.05). The frequency of all studied echocardiographic variables was significantly higher in patients with PTE (P < 0.05).

Conclusion:

It is suggested that we could use the results of this study for utilizing the diagnostic process of PTE in patients with highly clinical suspicion of PTE and providing more validated decision. Using the results of this study, we could identify high-risk patients and made appropriate risk assessment for better management of patients with suspected PTE as well as reduce the rate of unnecessary CTPA and its related adverse consequences.

Mandatory adherence to diagnostic protocol increases the yield of CTPA for pulmonary embolism

Objectives

To determine if mandatory adherence to a diagnostic protocol increases the rate of computed tomography pulmonary angiographies (CTPAs) positive for pulmonary embolism (PE)—the so-called diagnostic yield. Further, we aim to identify factors associated with this diagnostic yield.

Methods

We included all patients with suspected PE requiring CTPA from 9 January 2014 t0 3 June 2014. The requesting physicians were forced to follow diagnostic workup for PE by calculating a Wells score and, if necessary, determining D-dimer level. The percentage of positive CTPA scans was calculated and compared with our previous cohort (Walen et al. Insights Imaging 2014;5(2):231–236). Odds ratios were calculated as a measure of association between dichotomous variables and CTPA findings.

Results

Of 250 scans, 74 were positive (29.6 % [95 % CI, 24.3-35.5 %]) and 175 were negative (70 %). The percentage positive scans increased with 6.6 % and the percentage negative scans decreased with 3.1 %. This change was statistically significant (p = 0.001). Independent clinical predictors of diagnostic yield were previous deep venous thrombosis (DVT) (OR, 3.22; p = 0.013) and clinical signs of DVT (OR, 2.71; p = 0.012). Chronic obstructive pulmonary disease (COPD) was negatively associated with PE (OR, 0.33; p = 0.045).

Conclusions

This study shows that mandatory adherence to a diagnostic protocol increases the yield of CTPA for PE in our centre.

Main Messages

• Mandatory adherence to diagnostic protocol increases the yield of CTPA for PE

• Previous DVT and signs of DVT were associated with a higher yield

• No patients with a low Wells score and a low D-dimer had PE

Prognosis of patients with suspected pulmonary embolism in Buenos Aires: a prospective cohort study

BACKGROUND

The prognosis of patients with suspected pulmonary embolism (PE) in whom PE has been ruled out (RPE) is unclear. We aimed to evaluate survival and diagnosis of new cancer in suspected PE patients at follow up.

METHODS

A prospective cohort study nested in a prospective Institutional Registry of Venous Thromboembolic Disease was performed between 2006 and 2011. This study was designed to evaluate all consecutive, incident cases of suspected PE in adults. The study was performed at the Hospital Italiano de Buenos Aires, a tertiary level hospital, in hospitalized patients and outpatients. Suspected PE cases were collected using a computerized system that alerts whenever a physician requests pulmonary angiography, angiotomography, or ventilation-perfusion scintigraphy. PE was defined by pre-specified criteria and RPE was defined when diagnostic tests were negative for PE.

RESULTS

We included 1736 cases of suspected PE. The prevalence of PE was 29% (n = 504). There was no difference in the overall survival at 30 days and follow-up between PE and RPE patients. The presence of provoked or unprovoked venous thromboembolic disease in these patients did not affect survival. The main causes of death were PE in the confirmed PE group (60%), and neoplasm (42%) and sepsis (37%) in the RPE group. Survival at 90 days was 63% for PE (95% CI 58-67%) and 67% for RPE patients (95% CT 64-69%). At follow-up, there was no difference in diagnosis of new cancer between PE and RPE patients (2% vs 2%, p = 0.82), even when taking into account the unprovoked group.

CONCLUSIONS

Even when the main cause of death in PE patients is PE itself, the overall mortality is similar between PE and RPE patients. The reason for this finding could be because of the more frequent and severe comorbidities in RPE than in PE patients.

TRIAL REGISTRATION

HomeClinicalTrial.gov: NCT01372514.

CT findings and long-term mortality after pulmonary embolism

OBJECTIVE

The utility of CT findings in predicting long-term mortality in patients with acute pulmonary embolism (PE) is unknown. The purpose of this study is to retrospectively determine whether three CT findings--increased embolic burden, interventricular septal bowing toward the left ventricle, and right ventricle-to-left ventricle (RV/LV) diameter ratio greater than 1--are independent predictors of long-term all-cause mortality after acute PE.

MATERIALS AND METHODS

A total of 1105 patients (47% female; mean age, 63 ± 16 years) with CT scans positive for PE from January 1, 1997, to December 31, 2002, were included. Scans were independently interpreted by two observers, with a third independent observer reviewing discrepant cases. CT findings and clinical information were compared with all-cause mortality using univariate and multivariate logistic regression analyses.

RESULTS

The median duration of survival was 6.2 years following acute PE, with estimated 10-year survival of 37.4%. CT-derived embolic burden was associated with a very small decrease in long-term all-cause mortality in both univariate (hazard ratio [HR], 0.97; p < 0.001) and multivariate (HR, 0.97; p < 0.001) analyses. Interventricular septal bowing and RV/LV diameter ratio were not significantly associated with long-term all-cause mortality.

CONCLUSION

CT findings are not predictive of decreased long-term survival after acute PE.

Prognostic value of the Geneva prediction rule in patients in whom pulmonary embolism is ruled out

OBJECTIVES

The prognosis of patients in whom pulmonary embolism (PE) is suspected but ruled out is poorly understood. We evaluated whether the initial assessment of clinical probability of PE could help to predict the prognosis for these patients.

DESIGN

Retrospective analysis of data obtained during a prospective multicentre management study.

SETTING

Six general and teaching hospitals in Belgium, France and Switzerland.

SUBJECTS

In 1334 patients in whom PE was ruled out, 3-month mortality data were available (hospital readmission status was unknown for three patients) and clinical probability was evaluated with the revised Geneva score (RGS).

MAIN OUTCOME MEASURES

Three-month mortality and readmission rates.

RESULTS

Three-month mortality and readmissions rates were 3% and 19%, respectively and differed significantly depending on the RGS-determined PE probability group (P<0.001). When compared with patients presenting with a low probability, the risk of death after 3 months was higher in cases of intermediate or high RGS-based probability {odds ratio: 8.7 [95% confidence interval (CI): 2.7-28.5] and 22.6 (95%CI: 2.1-241.2), respectively}. The readmission risk increased with PE probability group (P<0.001). The main causes of death were cancer, respiratory failure and cardiovascular failure. In total, 86% of patients with low RGS-based probability were alive and had not been readmitted to hospital, whereas other patients had a twofold increased risk of death or readmission during the 3-month follow-up. The simplified Geneva score, calculated a posteriori, gave similar results.

CONCLUSIONS

Initial assessment of clinical probability may help to stratify prognosis of patients in whom PE has been ruled out. Patients with a low probability of PE have a good prognosis. Whether patients with higher probability might benefit from more vigilant care should be evaluated.