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Bhangu G, Murray A, Qayyum A, Goumeniouk N, Goodacre S, Hunt BJ, Touhami O, Tester J, Rees M, Hammerschlag G, Pascoe D, Ronksley PE, King JA, Choi H, McDermott S, Le Gal G, Skeith L. Diagnostic strategies in postpartum individuals with suspected venous thromboembolism: A scoping review. Thromb Res 2024; 236:108-116. [PMID: 38422980 DOI: 10.1016/j.thromres.2024.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 02/02/2024] [Accepted: 02/13/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND The risk of venous thromboembolism (VTE) is increased postpartum and contributes to important morbidity and mortality. While there have been advances in evaluating diagnostic algorithms for suspected VTE during pregnancy, there is limited data for postpartum individuals. OBJECTIVE We conducted a scoping review to describe and evaluate diagnostic strategies used to investigate suspected VTE in postpartum individuals. METHODS A comprehensive search strategy was conducted in Ovid MEDLINE, Embase and the Cochrane Central Register of Controlled Trials (January 1, 2000-September 30, 2022) to identify original articles that reported on diagnostic strategies in postpartum individuals with suspected VTE. We extracted demographics, clinical decision rules used, D-dimer and imaging completed, including test performance and VTE outcomes. RESULTS A total of 13 studies conducted across 11 countries with separate postpartum data were included for 759 individuals with suspected PE (n = 634) or DVT (n = 125), including unpublished data (n = 251). Among those with suspected PE, computed tomography pulmonary angiography was conducted more commonly (n = 522) than ventilation-perfusion scans (n = 69), with PE positivity rates that ranged from 4 %-27.6 % and 0-50 % across studies, respectively. Among 131 postpartum individuals with suspected PE who had a D-dimer measured, only 4.6 % (6/131) had a negative D-dimer test. For postpartum individuals with suspected DVT, the most common diagnostic test was compression ultrasonography (positivity rate 12.2 %-18.6 %). There were limited retrospective data evaluating the clinical decision rules. CONCLUSIONS There are heterogeneous approaches globally in the diagnosis of suspected postpartum VTE. Limited high-quality data available underscores the need for more robust evidence to inform clinical practice.
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Affiliation(s)
- Gurjeet Bhangu
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Alistair Murray
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Areeb Qayyum
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Natasha Goumeniouk
- Department of Emergency Medicine, University of Calgary, Calgary, AB, Canada
| | - Steve Goodacre
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Beverley J Hunt
- Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Omar Touhami
- Gynecologic Oncology Division, Department of Obstetrics and Gynecology, Hôpital Charles-LeMoyne, Sherbrooke University, Quebec, Canada
| | - Jodie Tester
- Department of Respiratory Medicine and Sleep Disorders, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Megan Rees
- Department of Respiratory Medicine and Sleep Disorders, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Gary Hammerschlag
- Department of Respiratory Medicine and Sleep Disorders, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Diane Pascoe
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia; Department of Radiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Paul E Ronksley
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - James A King
- Centre for Health Informatics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Alberta SPOR Support Unit Data Platform, Alberta Health Services, Calgary, Alberta, Canada
| | - Hyun Choi
- Emergency Department, University Hospital Lewisham, London, United Kingdom
| | - Shaunagh McDermott
- Thoracic Imaging Division, Department of Radiology, Massachusetts General Hospital, Boston, MA, United States
| | - Gregoire Le Gal
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Leslie Skeith
- Department of Medicine, University of Calgary, Calgary, AB, Canada; Centre for Health Informatics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
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2
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Goyal SK, Wang JJ, McCandlish JA, Cronin PP, Barish M, Sanelli PC, Cohen SL. Ten-Year Trend in Advanced Imaging Utilization for Suspected Pulmonary Embolism in Pregnancy. J Am Coll Radiol 2024; 21:549-557. [PMID: 37775066 DOI: 10.1016/j.jacr.2023.08.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 08/18/2023] [Accepted: 08/25/2023] [Indexed: 10/01/2023]
Abstract
PURPOSE Advanced imaging is essential to diagnose pulmonary embolism (PE) in pregnancy, but there are associated maternal and fetal radiation risks. The purpose of this study was to evaluate the 10-year trend in advanced imaging utilization for the evaluation of suspected PE in pregnancy. METHODS The authors evaluated pregnant women with advanced imaging using CT pulmonary angiography (CTPA) or lung scintigraphy (LS) for evaluation of suspected PE presenting to two tertiary hospitals from 2007 to 2016. The rate of imaging was evaluated relative to positive PE rate and local pregnancy rate. positive PE was defined as a new acute PE finding on any advanced imaging within 3 days of first advanced imaging test. Local pregnancy rates were defined per 1,000 pregnancies in the county serviced by both hospitals. Chi-square testing was used to evaluate statistical significance (P < .05) in the utilization trend of advanced imaging and relative to local pregnancy rates and evaluations positive for PE. RESULTS A total of 707 pregnant patients were identified, of whom 92.5% (n = 654) underwent CTPA and 7.5% (n = 53) underwent LS. Regression analysis showed an average increase of 5.2 advanced imaging studies per year (P < .001), with 61 and 105 studies performed in 2007 and 2016, respectively. Additionally, there was an average increase of 0.08 (P < .001) advanced imaging studies per 1,000 local pregnancies per year, doubling from 0.7 in 2007 to 1.4 in 2016 (P < .001). Finally, there was a decrease of 0.004 (P = .009) in advanced imaging positive for PE, from 3% (2 of 61) in 2007 to 0% (0 of 100) in 2016. CONCLUSIONS Advanced imaging utilization increased by 72% over the 10-year window, driven by higher use of CTPA. Although the detection rate of PE on advanced imaging has decreased, the utilization rate among pregnant patients doubled during this period. These results highlight the need to consider the radiation risks and costs of advanced imaging in specific patient populations.
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Affiliation(s)
- Sameer K Goyal
- Department of Radiology, Northwell Health, Manhasset, New York
| | - Jason J Wang
- The Feinstein Institutes for Medical Research, Manhasset, New York
| | | | - Paul P Cronin
- Department of Radiology and Imaging Science, Emory University Hospital, Atlanta, Georgia
| | - Matthew Barish
- Department of Radiology, Northwell Health, Manhasset, New York
| | - Pina C Sanelli
- Vice Chairman of Research and Executive Director, Imaging Clinical Effectiveness and Outcomes Research, Manhasset, New York
| | - Stuart L Cohen
- Department of Radiology, Imaging Clinical Effectiveness and Outcomes Research, Manhasset, New York.
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3
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Conrad TJ, Lau HX, Yerkovich ST, Alghamry A, Lee JC. Ventilation-perfusion scan for diagnosing pulmonary embolism: do chest x-rays matter? Nucl Med Commun 2024; 45:181-187. [PMID: 38247659 DOI: 10.1097/mnm.0000000000001802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
BACKGROUND Ventilation-perfusion (V/Q) scan coupled with single photon emission computed tomography (SPECT) is commonly used for the diagnosis of pulmonary embolism (PE). An abnormal chest x-ray (CXR) is deemed to hinder the interpretation of V/Q scan and therefore a normal CXR is recommended prior to V/Q scan. AIMS To determine if an abnormal CXR impacted on V/Q scan interpretation and subsequent management. METHODS A retrospective cohort analysis of all patients who underwent a V/Q scan for diagnosis of suspected acute PE between March 2016 and 2022 was performed. CXR reports were reviewed and classified as normal or abnormal. Low-dose computerised tomography was routinely performed in patients above the age of 70. Data regarding V/Q scan results and subsequent management including initiation of anticoagulation for PE or further diagnostic investigations were collected. RESULTS A total of 340 cases were evaluated. Of the positive V/Q scans (92/340), 98.3% of the normal CXR were anticoagulated compared to 100% of the abnormal CXR group. Of the negative V/Q scans (239/340), no cases were started on anticoagulation and no further investigations were performed across both normal and abnormal CXR groups. Indeterminate results occurred in only 9 cases with no significant difference in management between normal and abnormal CXR groups. CONCLUSION An abnormal CXR does not affect the reliability of V/Q scan interpretation in the diagnosis of PE when coupled with SPECT. Unless clinically indicated, the mandate by clinical society guidelines for a normal CXR prior to V/Q should be revisited.
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Affiliation(s)
- Thomas J Conrad
- Internal Medicine Services, The Prince Charles Hospital, Metro North Health, Brisbane
- Internal Medicine Services, Toowoomba Hospital, Darling Downs Health, Toowoomba, Queensland, Australia
| | - Han X Lau
- Internal Medicine Services, The Prince Charles Hospital, Metro North Health, Brisbane
| | - Stephanie T Yerkovich
- Child and Maternal Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
- Australian Centre for Health Services Innovation, Queensland University of Technology
| | - Alaa Alghamry
- Internal Medicine Services, The Prince Charles Hospital, Metro North Health, Brisbane
- Faculty of Medicine, The University of Queensland
| | - Joseph C Lee
- Faculty of Medicine, The University of Queensland
- Department of Medical Imaging, The Prince Charles Hospital, Metro North Health, Brisbane, Queensland, Australia
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Lili X, Shunlan D, Lixu J. Predictive Model for Pulmonary Embolism in Pregnant and Postpartum Women: A 10-Year Retrospective Study. Clin Appl Thromb Hemost 2023; 29:10760296231209930. [PMID: 37908100 PMCID: PMC10621299 DOI: 10.1177/10760296231209930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 09/09/2023] [Accepted: 10/09/2023] [Indexed: 11/02/2023] Open
Abstract
Background: Pulmonary embolism (PE) in pregnant and postpartum women is fatal, and risk assessment is crucial for effective and safe management, the aim of this retrospective study was to establish a nomogram for predicting the risk of PE in pregnant and postpartum women. Methods: Totally 343 subjects suspected of PE at the Obstetrics Department of Affiliated Dongyang Hospital of Wenzhou Medical University from January 2012 to December 2021 were retrospective analyzed in our study. Pregnant women suspected of PE and who underwent computed tomographic pulmonary angiography examination were included in the study. The least absolute shrinkage and selection operator regression technique was used to select the best prediction features, and multivariate logistic regression is used to build the prediction model. Bootstrap resampling 1000 times was used to validate the model visualized by nomogram. Evaluate the performance of the model from three aspects: identification, calibration and clinical utility. Results: Our predictive model indicated that chest tightness, anhelation, lactate, and D-dimer were associated with PE. The area under the receiver operating characteristic curve of the model was 0.836 (95% CI: [0.770-0.902]), indicating that our model had a good differential diagnostic performance. Good consistency between prediction and real observation was presented as the calibration curve. Decision curve analysis indicated that our model had a good net clinical benefit. Conclusions: We developed a novel numerical model for selecting risk factors for PE in pregnant and postpartum women. Our results may help obstetricians and gynaecologists to develop individualized treatment plans and PE prevention strategies.
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Affiliation(s)
- Xu Lili
- Department of Obstetrics, Affiliated Dongyang Hospital, Wenzhou Medical University, Dongyang, China
| | - Du Shunlan
- Department of Obstetrics, Affiliated Dongyang Hospital, Wenzhou Medical University, Dongyang, China
| | - Jin Lixu
- Department of Obstetrics, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
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McCandlish JA, Naidich JJ, Feizullayeva C, Makhnevich A, Barish MA, Sanelli PC, Cohen SL. Utilization of a Guideline-recommended Imaging Paradigm for Pregnant Patients With Suspicion of Pulmonary Embolism. J Thorac Imaging 2023; 38:23-28. [PMID: 36162078 DOI: 10.1097/rti.0000000000000676] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE A dose reduction imaging paradigm utilizing chest x-ray (CXR) to triage between computed tomography pulmonary angiography (CTPA) and lung scintigraphy (LS) was introduced in 2001 and adopted in 2012 by the American Thoracic Society/Society of Thoracic Radiology (ATS) guideline for the evaluation of pulmonary embolism in pregnancy. We aimed to assess the utilization of this imaging paradigm preadoption and postadoption by the ATS guideline, and identify factors associated with its utilization. MATERIALS AND METHODS This retrospective cohort study evaluated consecutive pregnant patients who received CTPA or LS for the evaluation of pulmonary embolism in pregnancy at 2 tertiary hospitals between September 2008 and March 2017, excluding 2012 for guideline release washout. Utilization of the imaging paradigm was defined per patient by the use of CXR before advanced imaging, with CTPA performed following positive CXR and LS performed following negative CXR. Multivariate analyses were performed to assess factors associated with utilization of the imaging paradigm. P <0.05 is considered significant. RESULTS Overall, 9.8% (63/643) of studies utilized the dose reduction imaging paradigm, 13.3% (34/256) before the guidelines, and 7.5% (29/387) after. Multivariable analysis showed that the dose reduction imaging paradigm utilization was higher for inpatients (odds ratio [OR]: 4.5) and outpatients (OR: 3.1) relative to the emergency department patients, and lower for second (OR: 0.3) and third (OR: 0.2) trimester patients, without significant differences by study priority, patient age, or patient race. CONCLUSIONS Guideline-recommended dose reduction imaging paradigm utilization was low, and decreased after guideline publication. Utilization varied by patient setting and trimester, which are potential targets for interventions to improve guideline compliance.
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Affiliation(s)
| | - Jason J Naidich
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead
- Department of Radiology, North Shore University Hospital/Northwell Health
| | - Chinara Feizullayeva
- Imaging Clinical Effectiveness and Outcomes Research (ICEOR) at Northwell Health
- Center for Health Innovations and Outcomes Research (CHIOR) at Northwell Health
- The Feinstein Institute for Medical Research at Northwell Health, Manhasset, NY
| | | | - Matthew A Barish
- Department of Radiology, North Shore University Hospital/Northwell Health
| | - Pina C Sanelli
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead
- Department of Radiology, North Shore University Hospital/Northwell Health
- Imaging Clinical Effectiveness and Outcomes Research (ICEOR) at Northwell Health
- Center for Health Innovations and Outcomes Research (CHIOR) at Northwell Health
- The Feinstein Institute for Medical Research at Northwell Health, Manhasset, NY
| | - Stuart L Cohen
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead
- Department of Radiology, North Shore University Hospital/Northwell Health
- Imaging Clinical Effectiveness and Outcomes Research (ICEOR) at Northwell Health
- Center for Health Innovations and Outcomes Research (CHIOR) at Northwell Health
- The Feinstein Institute for Medical Research at Northwell Health, Manhasset, NY
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6
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Pulmonary embolism in pregnancy and the puerperium. Best Pract Res Clin Obstet Gynaecol 2022; 85:96-106. [PMID: 35872145 DOI: 10.1016/j.bpobgyn.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 06/20/2022] [Indexed: 12/14/2022]
Abstract
Pulmonary embolism (PE) in pregnant women appears to be increasing. This could be related in part to improved health care allowing more women with risk factors to conceive, as well as increase in the high-risk groups which include pregnancies conceived on artificial reproductive technology, advancing maternal age, obesity, and caesarean deliveries. Prevention and early diagnosis with prompt effective treatment can reduce maternal mortality and improve pregnancy outcome, so that obstetricians should be on the lookout for venous thrombosis and PE, especially when in the majority of cases, risk factors only start to emerge or develop in the course of pregnancy and delivery. Management includes accurate diagnosis with ventilation/perfusion scan and CT pulmonary angiography, followed by effective anticoagulation and more aggressive measures such as thrombolysis as indicated, together with general supportive measures. Postpartum management should cover subsequent health issues, including breastfeeding, contraception, mood changes, and recurrence in subsequent pregnancies.
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Moumneh T, Penaloza A, Armand A, Robert-Ebadi H, Righini M, Douillet D, Le Gal G, Roy PM. Diagnostic de l’embolie pulmonaire dans le contexte de la grossesse. ANNALES FRANCAISES DE MEDECINE D URGENCE 2022. [DOI: 10.3166/afmu-2022-0375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Les problématiques posées par la prise en charge de la femme enceinte suspecte d’embolie pulmonaire (EP) aux urgences sont multiples. Les modifications physiologiques au cours de la grossesse majorent les sollicitations médicales pour des tableaux de douleur thoracique, de dyspnée, de malaise… En parallèle, ces manifestations aux cours de la grossesse peuvent se confondre avec les éléments évocateurs d’une EP et interférer sur nos capacités d’appréciation de sa probabilité. Enfin, l’élévation physiologique des D-dimères et le taux d’imageries thoraciques non conclusives complexifient la démarche diagnostique. C’est pourtant dans le contexte de la grossesse qu’il est particulièrement souhaitable de ne pas manquer un diagnostic d’EP, tout en évitant d’exposer inutilement la patiente et son foetus à l’imagerie thoracique. Pour aider dans les prises de décision, deux stratégies ont été validées dans le contexte de la grossesse. La première repose sur le score de Genève, incluant la réalisation d’une échographie de compression proximale chez les patientes à probabilité forte ou ayant un D-dimère supérieur à 500 μg/L. La seconde repose sur l’algorithme YEARS, avec réalisation d’une échographie uniquement chez les patientes ayant des symptômes évocateurs d’une thrombose veineuse des membres inférieurs associée, puis un dosage des D-dimères avec un seuil à 500 ou 1 000 μg/L en fonction de la probabilité clinique. La fiabilité de ces deux stratégies a été démontrée. La première stratégie présente l’avantage de ne reposer que sur des données objectives, et la deuxième de reposer le seuil décisionnel à 1 000 μg/L chez les patientes n’ayant aucun des critères YEARS.
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Mccandlish JA, Feizullayeva C, Spyropoulos A, Cronin PP, Naidich J, Brenner B, Mcginn T, Sanelli PC, Cohen SL. Comparison of guidelines for evaluation of suspected PE in pregnancy: a cost-effectiveness analysis. Chest 2021; 161:1628-1641. [PMID: 34914975 DOI: 10.1016/j.chest.2021.11.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 11/11/2021] [Accepted: 11/27/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Pulmonary embolism (PE) remains a leading cause of maternal mortality, yet diagnosis remains challenging. International diagnostic guidelines vary significantly in their recommendations, making it difficult to determine an optimal policy for evaluation. RESEARCH QUESTION Which societal-level diagnostic guideline for evaluation of suspected PE in pregnancy is an optimal policy in terms of its cost-effectiveness? STUDY DESIGN AND METHODS We constructed a complex Markov decision model to evaluate the cost-effectiveness of each identified societal guideline for diagnosis of PE in pregnancy. Our model accounted for risk stratification, empiric treatment, diagnostic testing strategies, as well as short- and long-term effects from PE, treatment with low-molecular weight heparin, and radiation exposure from advanced imaging. We considered clinical and cost outcomes of each guideline from a U.S. health care system perspective with a lifetime horizon. Clinical effectiveness and costs were measured in time-discounted quality-adjusted life years (QALYs) and U.S. dollars respectively. Strategies were compared using the incremental cost-effectiveness ratio (ICER) with a willingness-to-pay threshold of $100,000 per QALY. One-way, multi-way, and probabilistic sensitivity analyses were performed. RESULTS We identified six international societal-level guidelines. Base-case analysis showed the guideline proposed by the American Thoracic Society-Society of Thoracic Radiology (ATS-STR) yielded the highest health benefits (22.90 QALYs) and was cost-effective, with an ICER of $7,808 over the guideline proposed by the Australian Society of Thrombosis and Haemostasis and the Society of Obstetric Medicine of Australia and New Zealand (ASTH-SOMANZ). All remaining guidelines were dominated. The ATS-STR guideline-recommended strategy yielded an expected additional 2.7 QALYs per 100 patients evaluated over the ASTH-SOMANZ. Conclusions were robust to sensitivity analyses, with the ATS-STR guideline optimal in 86% of probabilistic sensitivity analysis scenarios. INTERPRETATION The ATS-STR guideline for diagnosis of suspected PE in pregnancy is cost-effective and generates better expected health outcomes than guidelines proposed by other medical societies.
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Affiliation(s)
- John Austin Mccandlish
- Imaging Clinical Effectiveness and Outcomes Research (ICEOR), Department of Radiology, Northwell Health, Manhasset, New York; Center for Health Innovations and Outcomes Research (CHIOR), Feinstein Institutes for Medical Research and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York; Georgia Institute of Technology, Atlanta, Georgia
| | - Chinara Feizullayeva
- Imaging Clinical Effectiveness and Outcomes Research (ICEOR), Department of Radiology, Northwell Health, Manhasset, New York; Center for Health Innovations and Outcomes Research (CHIOR), Feinstein Institutes for Medical Research and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Alex Spyropoulos
- The Institute for Health System Science, The Feinstein Institutes for Medical Research and The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA; Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital, New York, NY, USA; Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Paul P Cronin
- Emory University Hospital Department Of Radiology and Imaging Science, Atlanta, Georgia
| | - Jason Naidich
- Imaging Clinical Effectiveness and Outcomes Research (ICEOR), Department of Radiology, Northwell Health, Manhasset, New York
| | - Benjamin Brenner
- Department of Hematology, Rambam Health Care Campus, Haifa, Israel; The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel; Department of Obstetrics and Gynaecology, The First I.M. Sechenov Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Thomas Mcginn
- Center for Health Innovations and Outcomes Research (CHIOR), Feinstein Institutes for Medical Research and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Pina C Sanelli
- Imaging Clinical Effectiveness and Outcomes Research (ICEOR), Department of Radiology, Northwell Health, Manhasset, New York; Center for Health Innovations and Outcomes Research (CHIOR), Feinstein Institutes for Medical Research and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Stuart L Cohen
- Imaging Clinical Effectiveness and Outcomes Research (ICEOR), Department of Radiology, Northwell Health, Manhasset, New York; Center for Health Innovations and Outcomes Research (CHIOR), Feinstein Institutes for Medical Research and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York.
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Stolberg S, Mudawi D, Dean K, Cheng A, Barraclough R. Investigation and management of pulmonary embolism 2: specific clinical conditions. Br J Hosp Med (Lond) 2021; 82:1-6. [PMID: 34338010 DOI: 10.12968/hmed.2021.0286b] [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: 11/11/2022]
Abstract
Pulmonary embolism remains a common and potentially deadly disease, despite advances in diagnostic imaging, treatment and prevention. Managing pulmonary embolism requires a multifactorial approach involving risk stratification, determining appropriate diagnostics and selecting individualised therapy. The first part of this article reviewed the pathophysiology, risk factors, clinical presentation, diagnostic evaluation and therapeutic management and early outpatient management of pulmonary embolism. This second part summarises pulmonary embolism in the setting of pregnancy, COVID-19, recurrent disease and chronic thromboembolic pulmonary hypertension.
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Affiliation(s)
- Stephanie Stolberg
- Department of Respiratory Medicine, Wythenshawe Hospital, Manchester, UK
| | - Dalia Mudawi
- Department of Respiratory Medicine, Wythenshawe Hospital, Manchester, UK
| | - Katrina Dean
- Department of Respiratory Medicine, Wythenshawe Hospital, Manchester, UK
| | - Andrew Cheng
- Department of Respiratory Medicine, Wythenshawe Hospital, Manchester, UK
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10
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Bates SM. Pulmonary Embolism in Pregnancy. Semin Respir Crit Care Med 2021; 42:284-298. [PMID: 33548928 DOI: 10.1055/s-0041-1722867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Even though venous thromboembolism is a leading cause of maternal mortality in high-income countries, there are limited high-quality data to assist clinicians with the management of pulmonary embolism in this patient population. Diagnosis, prevention, and treatment of pregnancy-associated pulmonary embolism are complicated by the need to consider fetal, as well as maternal, well-being. Recent studies suggest that clinical prediction rules and D-dimer testing can reduce the need for diagnostic imaging in a subset of patients. Low-molecular-weight heparin is the preferred anticoagulant for both prophylaxis and treatment in this setting. Direct oral anticoagulants are contraindicated during pregnancy and in breastfeeding women. Thrombolysis or embolectomy should be considered for pregnant women with pulmonary embolism complicated by hemodynamic instability. Treatment of pregnancy-associated pulmonary embolism should be continued for at least 3 months, including 6 weeks postpartum. Management of anticoagulants at the time of delivery should involve a multidisciplinary individualized approach that uses shared decision making to take patient and caregiver values and preferences into account.
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Affiliation(s)
- Shannon M Bates
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
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11
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Jewell KE, Lee ST, Trubiano J, Lau E, Scott AM. Ventilation perfusion lung SPECT/CT in pregnancy during COVID-19. Intern Med J 2021; 50:1588-1590. [PMID: 33354886 DOI: 10.1111/imj.15089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 09/06/2020] [Accepted: 09/06/2020] [Indexed: 01/22/2023]
Affiliation(s)
- Kerry E Jewell
- Department of Molecular Imaging and Therapy, Austin Health, Melbourne, Victoria, Australia
| | - Sze Ting Lee
- Department of Molecular Imaging and Therapy, Austin Health, Melbourne, Victoria, Australia.,Olivia Newton-John Cancer Research Institute, Austin Health, Melbourne, Victoria, Australia.,School of Cancer Medicine, La Trobe University, Melbourne, Victoria, Australia
| | - Jason Trubiano
- Department of Infectious Disease, Austin Health, Mebourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Austin Health, Melbourne, Victoria, Australia
| | - Eddie Lau
- Department of Molecular Imaging and Therapy, Austin Health, Melbourne, Victoria, Australia.,Department of Radiology, Austin Health, Melbourne, Victoria, Australia
| | - Andrew M Scott
- Department of Molecular Imaging and Therapy, Austin Health, Melbourne, Victoria, Australia.,Olivia Newton-John Cancer Research Institute, Austin Health, Melbourne, Victoria, Australia.,School of Cancer Medicine, La Trobe University, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Austin Health, Melbourne, Victoria, Australia
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12
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Sin D, McLennan G, Rengier F, Haddadin I, Heresi GA, Bartholomew JR, Fink MA, Thompson D, Partovi S. Acute pulmonary embolism multimodality imaging prior to endovascular therapy. Int J Cardiovasc Imaging 2020; 37:343-358. [PMID: 32862293 PMCID: PMC7456521 DOI: 10.1007/s10554-020-01980-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 08/19/2020] [Indexed: 12/15/2022]
Abstract
The manuscript discusses the application of CT pulmonary angiography, ventilation–perfusion scan, and magnetic resonance angiography to detect acute pulmonary embolism and to plan endovascular therapy. CT pulmonary angiography offers high accuracy, speed of acquisition, and widespread availability when applied to acute pulmonary embolism detection. This imaging modality also aids the planning of endovascular therapy by visualizing the number and distribution of emboli, determining ideal intra-procedural catheter position for treatment, and signs of right heart strain. Ventilation–perfusion scan and magnetic resonance angiography with and without contrast enhancement can also aid in the detection and pre-procedural planning of endovascular therapy in patients who are not candidates for CT pulmonary angiography.
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Affiliation(s)
- David Sin
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - Gordon McLennan
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - Fabian Rengier
- Section of Emergency Radiology, Clinic for Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Ihab Haddadin
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - Gustavo A Heresi
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - John R Bartholomew
- Section of Vascular Medicine, Heart and Vascular Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - Matthias A Fink
- Section of Emergency Radiology, Clinic for Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Dustin Thompson
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - Sasan Partovi
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA.
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13
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Elgendy IY, Fogerty A, Blanco-Molina Á, Rosa V, Schellong S, Skride A, Portillo J, Lopez-Miguel P, Monreal M, Weinberg I. Clinical Characteristics and Outcomes of Women Presenting with Venous Thromboembolism during Pregnancy and Postpartum Period: Findings from the RIETE Registry. Thromb Haemost 2020; 120:1454-1462. [PMID: 32717760 DOI: 10.1055/s-0040-1714211] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Although venous thromboembolism (VTE) is a leading cause of maternal mortality, there is a paucity of real-world clinical data on clinical presentation and management of VTE during pregnancy and postpartum period. Using data from the international RIETE (Registro Informatizado Enfermedad Trombo Embólica) registry, pregnant and postpartum women with VTE were identified. Baseline characteristics, risk factors, therapies, and outcomes were compared. From March 2001 to July 2019, 596 pregnant and 523 postpartum women had symptomatic, objectively confirmed VTE. Pregnant or postpartum women were less likely to have another risk factor for VTE (i.e., immobility, cancer, recent travel) than nonpregnant women aged < 50 years. The prevalence of thrombophilia was higher among pregnant and postpartum women compared with nonpregnant women (53.2% vs. 46%). Pulmonary embolism (PE) was less commonly diagnosed in pregnant versus postpartum women (27% vs. 42%). Pregnant women with PE were commonly treated with low molecular weight heparin (73% vs. 29%), and received more inferior vena cava filters (6.0% vs. 4.2%) compared with postpartum women. By 90 days, one pregnant and one postpartum woman died after PE, and one died after a deep venous thrombosis. The incidence of recurrent VTE was low. In this largest cohort of pregnant and postpartum women with confirmed VTE, we found that pregnant and postpartum women with VTE were unlikely to present with other risk factors for VTE. Adverse outcomes in our study were uncommon.
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Affiliation(s)
- Islam Y Elgendy
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Annemarie Fogerty
- Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | | | - Vladimir Rosa
- Department of Internal Medicine, Hospital Universitario Virgen de Arrixaca, Murcia, Spain
| | - Sebastian Schellong
- Department of Medical Clinic, Municipal Hospital of Dresden Friedrichstadt, Dresden, Germany
| | - Andris Skride
- Department of Cardiology, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - José Portillo
- Department of Internal Medicine, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
| | - Patricia Lopez-Miguel
- Department of Pneumonology, Hospital General Universitario de Albacete, Albacete, Spain
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Ido Weinberg
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, United States
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Rotzinger DC, Dunet V, Ilic V, Hugli OW, Meuli RA, Schmidt S. Pulmonary embolism during pregnancy: a 17-year single-center retrospective MDCT pulmonary angiography study. Eur Radiol 2020; 30:1780-1789. [PMID: 31728689 PMCID: PMC7033070 DOI: 10.1007/s00330-019-06501-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 08/23/2019] [Accepted: 10/08/2019] [Indexed: 12/25/2022]
Abstract
OBJECTIVES To determine the prevalence of pulmonary embolism (PE) and alternative diagnoses detected by computed tomography pulmonary angiography (CTPA) in pregnant women; and to assess changes over time regarding radiation dose, technical quality, and examination frequency. MATERIALS AND METHODS This retrospective study included all pregnant women referred for CTPA due to clinically suspected PE over 17 years. Two blinded radiologists reviewed the CTPAs in consensus with regard to PE, alternative diagnoses, and technical quality. We retrieved patient data regarding radiation dose metrics and associated clinical and laboratory parameters. Subgroup comparisons were performed (Wilcoxon and Kruskal-Wallis tests). RESULTS Of the 237 identified patients, 8 (3.3%) were excluded due to inadequate technical CTPA quality, and 229 patients were analyzed (mean age, 31.7 years; mean gestational age, 28 ± 7 weeks). The four different CT systems used over the study period had similar technical quality (p = 0.28). Of 229 patients 16 (7%) patients had PE, 144 (62.9%) had no abnormal findings, and 69 (30.1%) had an alternative diagnosis (consolidation, other pulmonary opacities, pleural effusion, and basal atelectasis). Gestational age, symptoms, and D-dimer levels were not significantly different between patients with or without PE (p > 0.05). Over time, radiation dose exposure decreased by 30% (p < 0.001), while the number of annual examinations increased by > 4-folds. CONCLUSIONS In pregnant women, CTPA rarely indicates PE and more often shows alternative diagnoses. Over 17 years, the use of CTPA in pregnancy has notably increased, while the radiation dose exposure has decreased by one third. KEY POINTS • The use of CTPA in pregnancy has steadily risen over the last 17 years • In pregnant women, CTPA rarely reveals PE and more often shows alternative diagnoses • Recent technical improvements have substantially decreased the radiation dose exposure inherent in CTPA without reducing diagnostic image quality.
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Affiliation(s)
- David C Rotzinger
- Department of Diagnostic and Interventional Radiology, Emergency Radiology Division, Lausanne University Hospital (CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland.
- Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), Lausanne, Switzerland.
| | - Vincent Dunet
- Department of Diagnostic and Interventional Radiology, Emergency Radiology Division, Lausanne University Hospital (CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland
- Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Vesna Ilic
- Centre d'Imagerie du Nord Vaudois (CINOV), Yverdon-les-Bains, Switzerland
| | - Olivier W Hugli
- Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), Lausanne, Switzerland
- Emergency Department, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Reto A Meuli
- Department of Diagnostic and Interventional Radiology, Emergency Radiology Division, Lausanne University Hospital (CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland
- Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Sabine Schmidt
- Department of Diagnostic and Interventional Radiology, Emergency Radiology Division, Lausanne University Hospital (CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland
- Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), Lausanne, Switzerland
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Cohen SL, Feizullayeva C, McCandlish JA, Sanelli PC, McGinn T, Brenner B, Spyropoulos AC. Comparison of international societal guidelines for the diagnosis of suspected pulmonary embolism during pregnancy. LANCET HAEMATOLOGY 2020; 7:e247-e258. [PMID: 32109405 DOI: 10.1016/s2352-3026(19)30250-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 11/13/2019] [Accepted: 11/18/2019] [Indexed: 10/24/2022]
Abstract
Pregnancy-associated pulmonary embolism is one of the leading causes of maternal mortality. Diagnosis of pulmonary embolism in pregnancy is challenging, with symptoms of pulmonary embolism mimicking those of pregnancy. Several key components such as clinical prediction tools, risk stratification, laboratory tests, and imaging widely used for diagnosis of pulmonary embolism in the non-pregnant population show limitations for diagnosis in pregnancy. Further, because of the difficulty of studying pregnant patients, high-quality research evaluating the performance of these diagnostic components in pregnancy is scarce. Seven international medical society guidelines present clinical diagnostic pathways for evaluation of pulmonary embolism in pregnancy that show conflicting recommendations on the use of these diagnostic components. This Review assesses all key components of diagnostic clinical pathways recommended by guidelines for evaluation of pulmonary embolism in pregnancy, reviews current evidence, compares the guideline recommendations with respect to each key component, and provides our preferred diagnostic pathway. It provides the guidelines and available data needed for informed decision making to diagnose pulmonary embolism in pregnancy.
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Affiliation(s)
- Stuart L Cohen
- Imaging Clinical Effectiveness and Outcomes Research, Department of Radiology, Northwell Health, Manhasset, NY, USA; Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA.
| | - Chinara Feizullayeva
- Imaging Clinical Effectiveness and Outcomes Research, Department of Radiology, Northwell Health, Manhasset, NY, USA; Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - John A McCandlish
- Imaging Clinical Effectiveness and Outcomes Research, Department of Radiology, Northwell Health, Manhasset, NY, USA; Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA; Georgia Institute of Technology, Atlanta, GA, USA
| | - Pina C Sanelli
- Imaging Clinical Effectiveness and Outcomes Research, Department of Radiology, Northwell Health, Manhasset, NY, USA; Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Thomas McGinn
- Department of Medicine, Northwell Health, Manhasset, NY, USA; Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Benjamin Brenner
- Institute of Hematology, Rambam Health Care Campus and Technion, Israel Institute of Technology, Haifa, Israel; Department of Obstetrics and Gynaecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - Alex C Spyropoulos
- Department of Medicine, Northwell Health, Manhasset, NY, USA; Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
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16
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Cohen SL, Wang J, Mankerian M, Feizullayeva C, McCandlish JA, Barnaby D, Sanelli P, McGinn T. Evaluation of CTPA interpreted as limited in pregnant patients suspected for pulmonary embolism. Emerg Radiol 2019; 27:165-171. [PMID: 31813073 DOI: 10.1007/s10140-019-01728-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 09/06/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE The purpose of this study is to determine the rates of CT pulmonary angiography (CTPA) interpreted as limited and severely limited in pregnant patients suspected for pulmonary embolism (PE), and to evaluate factors that influence these rates. METHODS This is a retrospective study with CTPA for evaluation of PE in pregnancy across a large health system from 2006 to 2017. CTPA was classified as limited from the radiology report with a subset of those studies classified as severely limited. Bivariate and multivariate analysis was performed for limited and severely limited rates with maternal age and patient size as a continuous variable and race, trimester, patient location study priority status, and result of chest radiograph before CTPA as categorical variables. RESULTS 874 patients with 33% of studies limited and 4% of studies severely limited. Multivariate logistic regression of CTPA studies revealed decreasing patient age (OR 0.967, p = 0.0129) and increasing patient size (OR 1.013, p < 0.0001). Studies performed in the second trimester (OR 1.869, p = 0.0242) and third trimester (OR 2.314, p = 0.0021) were more likely to be reported as limited (each p < 0.05). Increasing patient size (OR 1.017, p = 0.0046) was the only significant predictor of severely limited versus non-severely limited studies. CONCLUSION CTPA interpreted as limited in pregnancy are common and may be associated with younger age, larger patient size, and second and third trimesters. However, severely limited interpretations are much less common, with patient size the only significant predictor.
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Affiliation(s)
- S L Cohen
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA. .,Northwell Health Imaging, 600 Community Drive, Manhasset, NY, 11030, USA. .,Imaging Clinical Effectiveness & Outcomes Research Program at Northwell Health, 600 Community Drive, Manhasset, NY, 11030, USA. .,Feinstein Institute for Medical Research at Northwell Health, 600 Community Drive, Manhasset, NY, 11030, USA.
| | - J Wang
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.,Imaging Clinical Effectiveness & Outcomes Research Program at Northwell Health, 600 Community Drive, Manhasset, NY, 11030, USA.,Feinstein Institute for Medical Research at Northwell Health, 600 Community Drive, Manhasset, NY, 11030, USA
| | - M Mankerian
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - C Feizullayeva
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.,Northwell Health Imaging, 600 Community Drive, Manhasset, NY, 11030, USA.,Imaging Clinical Effectiveness & Outcomes Research Program at Northwell Health, 600 Community Drive, Manhasset, NY, 11030, USA.,Feinstein Institute for Medical Research at Northwell Health, 600 Community Drive, Manhasset, NY, 11030, USA
| | | | - D Barnaby
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.,Feinstein Institute for Medical Research at Northwell Health, 600 Community Drive, Manhasset, NY, 11030, USA.,Northwell Health Emergency Medicine, Manhasset, NY, USA
| | - P Sanelli
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.,Northwell Health Imaging, 600 Community Drive, Manhasset, NY, 11030, USA.,Imaging Clinical Effectiveness & Outcomes Research Program at Northwell Health, 600 Community Drive, Manhasset, NY, 11030, USA.,Feinstein Institute for Medical Research at Northwell Health, 600 Community Drive, Manhasset, NY, 11030, USA
| | - T McGinn
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.,Feinstein Institute for Medical Research at Northwell Health, 600 Community Drive, Manhasset, NY, 11030, USA.,Northwell Health Internal Medicine, Manhasset, NY, USA
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17
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Roy PM, Revel MP, Salaün PY, Sanchez O. [How to make the diagnosis of pulmonary embolism?]. Rev Mal Respir 2019; 38 Suppl 1:e7-e23. [PMID: 31734045 DOI: 10.1016/j.rmr.2019.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- P-M Roy
- F-CRIN INNOVTE, 42055 St-Étienne cedex 2, France; Département de médecine d'urgence et service de médecine vasculaire, CHU Angers, 49000 Angers, France; UMR 1083, UFR santé, Institut Mitovasc, université d'Angers, 49000 Angers, France
| | - M-P Revel
- Service de radiologie A, hôpital Cochin, Université de Paris, Assistance publique des Hôpitaux de Paris, 75014 Paris, France
| | - P-Y Salaün
- Inserm EA3878 (GETBO), service de médecine nucléaire, université de Bretagne occidentale, CHRU de Brest, 29200 Brest, France
| | - O Sanchez
- F-CRIN INNOVTE, 42055 St-Étienne cedex 2, France; Université de Paris, service de pneumologie et soins intensifs, AH-HP, hôpital Européen Georges-Pompidou, 75015 Paris, France; Innovations Thérapeutiques en Hémostase, INSERM UMRS 1140, 75006 Paris, France.
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18
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Bajc M, Schümichen C, Grüning T, Lindqvist A, Le Roux PY, Alatri A, Bauer RW, Dilic M, Neilly B, Verberne HJ, Delgado Bolton RC, Jonson B. EANM guideline for ventilation/perfusion single-photon emission computed tomography (SPECT) for diagnosis of pulmonary embolism and beyond. Eur J Nucl Med Mol Imaging 2019; 46:2429-2451. [PMID: 31410539 PMCID: PMC6813289 DOI: 10.1007/s00259-019-04450-0] [Citation(s) in RCA: 118] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 07/17/2019] [Indexed: 12/18/2022]
Abstract
These guidelines update the previous EANM 2009 guidelines on the diagnosis of pulmonary embolism (PE). Relevant new aspects are related to (a) quantification of PE and other ventilation/perfusion defects; (b) follow-up of patients with PE; (c) chronic PE; and (d) description of additional pulmonary physiological changes leading to diagnoses of left ventricular heart failure (HF), chronic obstructive pulmonary disease (COPD) and pneumonia. The diagnosis of PE should be reported when a mismatch of one segment or two subsegments is found. For ventilation, Technegas or krypton gas is preferred over diethylene triamine pentaacetic acid (DTPA) in patients with COPD. Tomographic imaging with V/PSPECT has higher sensitivity and specificity for PE compared with planar imaging. Absence of contraindications makes V/PSPECT an essential method for the diagnosis of PE. When V/PSPECT is combined with a low-dose CT, the specificity of the test can be further improved, especially in patients with other lung diseases. Pitfalls in V/PSPECT interpretation are discussed. In conclusion, V/PSPECT is strongly recommended as it accurately establishes the diagnosis of PE even in the presence of diseases like COPD, HF and pneumonia and has no contraindications.
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Affiliation(s)
- Marika Bajc
- Department of Clinical Sciences, Clinical Physiology and Nuclear Medicine, University of Lund, Lund, Sweden.
| | - Carl Schümichen
- University of Rostock, Formerly Clinic for Nuclear Medicine, Rostock, Germany
| | - Thomas Grüning
- Department of Nuclear Medicine, University Hospitals Plymouth, Plymouth, UK
| | - Ari Lindqvist
- Research Unit of Pulmonary Diseases, Clinical Research Institute, HUS Helsinki University Hospital, Helsinki, Finland
| | | | - Adriano Alatri
- Division of Angiology, Heart and Vessel Department, Lausanne University Hospital, Lausanne, Switzerland
| | - Ralf W Bauer
- RNS Gemeinschaftspraxis, Wiesbaden, Germany
- Department of Diagnostic and Interventional Radiology, Goethe University Frankfurt (Main), Frankfurt, Germany
| | - Mirza Dilic
- Clinic of Heart and Blood Vessel Disease, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Brian Neilly
- Department of Nuclear Medicine, Royal Infirmary, Glasgow, UK
| | - Hein J Verberne
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Roberto C Delgado Bolton
- Department of Diagnostic Imaging (Radiology) and Nuclear Medicine, University Hospital San Pedro and Centre for Biomedical Research of La Rioja (CIBIR), Logroño, La Rioja, Spain
| | - Bjorn Jonson
- Department of Clinical Sciences, Clinical Physiology and Nuclear Medicine, University of Lund, Lund, Sweden
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Abstract
Venous thromboembolism (VTE), referring to both deep vein thrombosis and pulmonary embolism, is a leading cause of death in the developed world during pregnancy. This increased risk is attributed to the Virchow triad, inherited thrombophilias, along with other standard risk factors, and continues for up to 6 to 12 weeks postpartum. During the peripartum period, women should be risk stratified and preventive measures should be initiated based on their risk. Diagnostic tests and treatment strategies commonly used in VTE differ in pregnancy. An understanding of these differences is imperative to diagnose with confidence and to treat appropriately.
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Affiliation(s)
- Christopher Deeb Dado
- Pulmonary and Critical Care Fellowship, Rhode Island Hospital, Warren Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI 02903, USA
| | - Andrew Tobias Levinson
- Department of Medicine, The Miriam Hospital, Warren Alpert Medical School of Brown University, 164 Summit Avenue, Providence, RI 02904, USA
| | - Ghada Bourjeily
- Department of Medicine, The Miriam Hospital, Warren Alpert Medical School of Brown University, 146 West River Street, Suite 11C, Providence, RI 02904, USA.
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21
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Goodacre S, Horspool K, Shephard N, Pollard D, Hunt BJ, Fuller G, Nelson-Piercy C, Knight M, Thomas S, Lecky F, Cohen J. Selecting pregnant or postpartum women with suspected pulmonary embolism for diagnostic imaging: the DiPEP diagnostic study with decision-analysis modelling. Health Technol Assess 2019; 22:1-230. [PMID: 30178738 DOI: 10.3310/hta22470] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Pulmonary embolism (PE) is a leading cause of death in pregnancy and post partum, but the symptoms of PE are common in normal pregnancy. Simple diagnostic tests are needed to select women for diagnostic imaging. OBJECTIVE To estimate the accuracy, effectiveness and cost-effectiveness of clinical features, decision rules and biomarkers for selecting pregnant or postpartum women with a suspected PE for imaging. DESIGN An expert consensus study to develop new clinical decision rules, a case-control study of women with a diagnosed PE or a suspected PE, a biomarker study of women with a suspected PE or diagnosed deep-vein thrombosis (DVT) and decision-analysis modelling. SETTING Emergency departments and consultant-led maternity units. PARTICIPANTS Pregnant/postpartum women with a diagnosed PE from any hospital reporting to the UK Obstetric Surveillance System research platform and pregnant/postpartum women with a suspected PE or diagnosed DVT at 11 prospectively recruiting sites. INTERVENTIONS Clinical features, decision rules and biomarkers. MAIN OUTCOME MEASURES Sensitivity, specificity, area under receiver operating characteristic (AUROC) curve, quality-adjusted life-years (QALYs) and health-care costs. RESULTS The primary analysis involved 181 women with PE and 259 women without PE in the case-control study and 18 women with DVT, 18 with PE and 247 women without either in the biomarker study. Most clinical features showed no association with PE. The AUROC curves for the clinical decision rules were as follows: primary consensus, 0.626; sensitive consensus, 0.620; specific consensus, 0.589; PE rule-out criteria, 0.621; simplified Geneva score, 0.579; Wells's PE criteria (permissive), 0.577; and Wells's PE criteria (strict), 0.732. The sensitivities and specificities of the D-dimer measurement were 88.4% and 8.8%, respectively, using a standard threshold, and 69.8% and 32.8%, respectively, using a pregnancy-specific threshold. Previous venous thromboembolism, long-haul travel, multiple pregnancy, oxygen saturation, recent surgery, temperature and PE-related chest radiograph abnormality were predictors of PE on multivariable analysis. We were unable to derive a rule through multivariable analysis or recursive partitioning with adequate accuracy. The AUROC curves for the biomarkers were as follows: activated partial thromboplastin time - 0.669, B-type natriuretic peptide - 0.549, C-reactive protein - 0.542, Clauss fibrinogen - 0.589, enzyme-linked immunosorbent assay D-dimer - 0.668, Innovance D-dimer (Siemens Healthcare Diagnostics Products GmbH, distributed by Sysmex UK Ltd, Milton Keynes, UK) - 0.651, mid-regional pro-atrial natriuretic peptide (MRproANP) - 0.524, prothrombin fragment 1 + 2 - 0.562, plasmin-antiplasmin - 0.639, Prothombin time - 0.613, thrombin generation lag time - 0.702, thrombin generation endogenous potential - 0.559, thrombin generation peak - 0.596, thrombin generation time to peak - 0.655, tissue factor - 0.531 and troponin - 0.597. The repeat analysis excluding women who had received anticoagulation was limited by the small number of women with PE (n = 4). The health economic analysis showed that a strategy of scanning all women with a suspected PE accrued more QALYs and incurred fewer costs than any selective strategy based on a clinical decision rule and was therefore the dominant strategy. LIMITATIONS The findings apply specifically to the diagnostic assessment of women with a suspected PE in secondary care. CONCLUSIONS Clinical features, decision rules and biomarkers do not accurately, effectively or cost-effectively select pregnant or postpartum women with a suspected PE for diagnostic imaging. FUTURE WORK New diagnostic technologies need to be developed to detect PE in pregnancy. TRIAL REGISTRATION Current Controlled Trials ISRCTN21245595. FUNDING DETAILS This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 47. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Steve Goodacre
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Kimberley Horspool
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Neil Shephard
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Daniel Pollard
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | | | - Gordon Fuller
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | | | - Marian Knight
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Steven Thomas
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Fiona Lecky
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Judith Cohen
- School of Health and Related Research, University of Sheffield, Sheffield, UK
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22
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Rate of Nondiagnostic Computerized Tomography Pulmonary Angiograms (CTPAs) Performed for the Diagnosis of Pulmonary Embolism in Pregnant and Immediately Postpartum Patients. Obstet Gynecol Int 2019; 2019:1432759. [PMID: 31049065 PMCID: PMC6458938 DOI: 10.1155/2019/1432759] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 02/11/2019] [Accepted: 03/12/2019] [Indexed: 11/18/2022] Open
Abstract
Objective To evaluate the nondiagnostic rate of computed tomography pulmonary angiography (CTPA) in pregnant and postpartum patients with suspected pulmonary embolism (PE) to determine whether CTPA or ventilation-perfusion (VQ) scan should be considered first line imaging in this patient population considering their equivalent accuracy and the greater radiation exposure to proliferating breast tissue of CTPA. Methods All pregnant/postpartum female patients between 18 and 50 years of age who had CTPA within the Eastern Health Authority between November 2012 and November 2016 were included. Each scan was evaluated for nondiagnosis based on two criteria: contrast density in the main pulmonary artery, and respiratory motion artefact. If either of these criteria were not met, the scan was labelled as nondiagnostic. Results The nondiagnostic rate overall was 43% (n=83). This is similar to current literature values for rates of CTPA nondiagnosis, and comparable to the reported diagnostic quality of the reporting radiologist. This is much greater compared to rates of ventilation/perfusion nondiagnosis in comparable populations. Even in patients with normal chest radiographs, which represents the main patient group where VQ may be considered as an alternative, the nondiagnostic rate of CT is much higher. Conclusion This is the first study to attempt to identify an objective method of determining nondiagnosis in pregnant and postpartum patients undergoing a CTPA. Our results strengthen the argument that alternative imaging should be considered when investigating for PE in this population in order to protect the proliferating breast tissue, and VQ scan should be considered especially in patients with normal chest X-rays.
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Tran HA, Gibbs H, Merriman E, Curnow JL, Young L, Bennett A, Tan CW, Chunilal SD, Ward CM, Baker R, Nandurkar H. New guidelines from the Thrombosis and Haemostasis Society of Australia and New Zealand for the diagnosis and management of venous thromboembolism. Med J Aust 2019; 210:227-235. [PMID: 30739331 DOI: 10.5694/mja2.50004] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is the third most common cardiovascular disease and, globally, more than an estimated 10 million people have it yearly. It is a chronic and recurrent disease. The symptoms of VTE are non-specific and the diagnosis should actively be sought once considered. The mainstay of VTE treatment is anticoagulation, with few patients requiring additional intervention. A working group of experts in the area recently completed an evidence-based guideline for the diagnosis and management of DVT and PE on behalf of the Thrombosis and Haemostasis Society of Australia and New Zealand (www.thanz.org.au/resources/thanz-guidelines). MAIN RECOMMENDATIONS The diagnosis of VTE should be established with imaging; it may be excluded by the use of clinical prediction rules combined with D-dimer testing. Proximal DVT or PE caused by a major surgery or trauma that is no longer present should be treated with anticoagulant therapy for 3 months. Proximal DVT or PE that is unprovoked or associated with a transient risk factor (non-surgical) should be treated with anticoagulant therapy for 3-6 months. Proximal DVT or PE that is recurrent (two or more) and provoked by active cancer or antiphospholipid syndrome should receive extended anticoagulation. Distal DVT caused by a major provoking factor that is no longer present should be treated with anticoagulant therapy for 6 weeks. For patients continuing with extended anticoagulant therapy, either therapeutic or low dose direct oral anticoagulants can be prescribed and is preferred over warfarin in the absence of contraindications. Routine thrombophilia testing is not indicated. Thrombolysis or a suitable alternative is indicated for massive (haemodynamically unstable) PE. CHANGES IN MANAGEMENT AS A RESULT OF THE GUIDELINE Most patients with acute VTE should be treated with a factor Xa inhibitor and be assessed for extended anticoagulation.
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Affiliation(s)
- Huyen A Tran
- Alfred Health, Melbourne, VIC.,Monash University, Melbourne, VIC
| | - Harry Gibbs
- Alfred Health, Melbourne, VIC.,Monash University, Melbourne, VIC
| | | | | | - Laura Young
- Auckland District Health Board, Auckland, New Zealand
| | | | | | | | | | | | - Harshal Nandurkar
- Monash University, Melbourne, VIC.,Australian Centre of Blood Diseases, Melbourne, VIC
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Abstract
Pulmonary embolism in pregnancy is a leading cause of maternal mortality. The clinical presentation is often nonspecific, making imaging essential for accurate diagnosis. After reviewing the literature on the radiologic diagnosis of pulmonary embolism in pregnancy, we concluded that both computed tomography pulmonary angiography and lung perfusion scintigraphy are sensitive with high positive predictive values in the presence of high clinical suspicion, but lung perfusion scintigraphy is recommended given lower maternal breast exposure to ionizing radiation and lower fetal contrast exposure. However, if a chest x-ray is abnormal, computed tomography pulmonary angiography is preferred due to high nondiagnostic rates of lung perfusion scintigraphy.
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Righini M, Robert-Ebadi H, Elias A, Sanchez O, Le Moigne E, Schmidt J, Le Gall C, Cornuz J, Aujesky D, Roy PM, Chauleur C, Rutschmann OT, Poletti PA, Le Gal G. Diagnosis of Pulmonary Embolism During Pregnancy: A Multicenter Prospective Management Outcome Study. Ann Intern Med 2018; 169:766-773. [PMID: 30357273 DOI: 10.7326/m18-1670] [Citation(s) in RCA: 116] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Data on the optimal diagnostic management of pregnant women with suspected pulmonary embolism (PE) are limited, and guidelines provide inconsistent recommendations on use of diagnostic tests. OBJECTIVE To prospectively validate a diagnostic strategy in pregnant women with suspected PE. DESIGN Multicenter, multinational, prospective diagnostic management outcome study involving pretest clinical probability assessment, high-sensitivity D-dimer testing, bilateral lower limb compression ultrasonography (CUS), and computed tomography pulmonary angiography (CTPA). (ClinicalTrials.gov: NCT00740454). SETTING 11 centers in France and Switzerland between August 2008 and July 2016. PATIENTS Pregnant women with clinically suspected PE in emergency departments. INTERVENTION Pulmonary embolism was excluded in patients with a low or intermediate pretest clinical probability and a negative D-dimer result. All others underwent lower limb CUS and, if results were negative, CTPA. A ventilation-perfusion (V/Q) scan was done if CTPA results were inconclusive. Pulmonary embolism was excluded if results of the diagnostic work-up were negative, and untreated pregnant women had clinical follow-up at 3 months. MEASUREMENTS The primary outcome was the rate of adjudicated venous thromboembolic events during the 3-month follow-up. RESULTS 441 women were assessed for eligibility, and 395 were included in the study. Among these, PE was diagnosed in 28 (7.1%) (proximal deep venous thrombosis found on ultrasonography [n = 7], positive CTPA result [n = 19], and high-probability V/Q scan [n = 2]) and excluded in 367 (clinical probability and negative D-dimer result [n = 46], negative CTPA result [n = 290], normal or low-probability V/Q scan [n = 17], and other reason [n = 14]). Twenty-two women received extended anticoagulation during follow-up, mainly for previous venous thromboembolic disease. The rate of symptomatic venous thromboembolic events was 0.0% (95% CI, 0.0% to 1.0%) among untreated women after exclusion of PE on the basis of negative results on the diagnostic work-up. LIMITATION There were several protocol deviations, reflecting the difficulty of performing studies in pregnant women with suspected PE. CONCLUSION A diagnostic strategy based on assessment of clinical probability, D-dimer measurement, CUS, and CTPA can safely rule out PE in pregnant women. PRIMARY FUNDING SOURCE Swiss National Foundation for Scientific Research, Groupe d'Etude de la Thrombose de Bretagne Occidentale, and International Society on Thrombosis and Haemostasis.
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Affiliation(s)
- Marc Righini
- Geneva University Hospitals, Geneva, Switzerland (M.R., H.R., O.T.R., P.P.)
| | - Helia Robert-Ebadi
- Geneva University Hospitals, Geneva, Switzerland (M.R., H.R., O.T.R., P.P.)
| | | | - Olivier Sanchez
- Université Paris Descartes, Sorbonne Paris Cité, and Hôpital Européen Georges Pompidou, Paris, France (O.S.)
| | - Emmanuelle Le Moigne
- INSERM UMR S 1140, Paris, France, F-CRIN INNOVTE, Saint-Etienne, France, and Université de Brest, Brest, France (E.L.)
| | - Jeannot Schmidt
- Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand, France (J.S.)
| | | | - Jacques Cornuz
- Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland (J.C.)
| | - Drahomir Aujesky
- Bern University Hospital, University of Bern, Bern, Switzerland (D.A.)
| | | | - Céline Chauleur
- INSERM U1059, University of Lyon, and University Hospital, Saint-Etienne, France (C.C.)
| | | | | | - Grégoire Le Gal
- Université de Brest, Brest, France, and Ottawa Health Research Institute, Ottawa, Ontario, Canada (G.L.)
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Tromeur C, van der Pol LM, Le Roux PY, Ende-Verhaar Y, Salaun PY, Leroyer C, Couturaud F, Kroft LJM, Huisman MV, Klok FA. Computed tomography pulmonary angiography versus ventilation-perfusion lung scanning for diagnosing pulmonary embolism during pregnancy: a systematic review and meta-analysis. Haematologica 2018; 104:176-188. [PMID: 30115658 PMCID: PMC6312023 DOI: 10.3324/haematol.2018.196121] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Accepted: 08/14/2018] [Indexed: 01/19/2023] Open
Abstract
Differences between computed tomography pulmonary angiography and ventilation-perfusion lung scanning in pregnant patients with suspected acute pulmonary embolism are not well-known, leading to ongoing debate on which test to choose. We searched in PubMed, EMBASE, Web of Science and the Cochrane Library databases and identified all relevant articles and abstracts published up to October 1, 2017. We assessed diagnostic efficiency, frequency of non-diagnostic results and maternal and fetal exposure to radiation exposure. We included 13 studies for the diagnostic efficiency analysis, 30 for the analysis of non-diagnostic results and 22 for the radiation exposure analysis. The pooled rate of false negative test results was 0% for both imaging strategies with overlapping confidence intervals. The pooled rates of non-diagnostic results with computed tomography pulmonary angiography and ventilation-perfusion lung scans were 12% (95% confidence interval: 8-17) and 14% (95% confidence interval: 10-18), respectively. Reported maternal and fetal radiation exposure doses were well below the safety threshold, but could not be compared between the two diagnostic methods given the lack of high quality data. Both imaging tests seem equally safe to rule out pulmonary embolism in pregnancy. We found no significant differences in efficiency and radiation exposures between computed tomography pulmonary angiography and ventilation-perfusion lung scanning although direct comparisons were not possible.
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Affiliation(s)
- Cécile Tromeur
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, the Netherlands .,Groupe d'Etude de la Thrombose de Bretagne Occidentale, University of Brest, Equipe d'Accueil 3878, Department of Internal Medicine and Chest Diseases, CHRU Brest, France.,Centre d'Investigation Clinique INSERM 1412, University of Brest, France
| | - Liselotte M van der Pol
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, the Netherlands.,Department of Internal Medicine, Haga Teaching Hospital, the Hague, the Netherlands
| | | | - Yvonne Ende-Verhaar
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, the Netherlands
| | | | - Christophe Leroyer
- Groupe d'Etude de la Thrombose de Bretagne Occidentale, University of Brest, Equipe d'Accueil 3878, Department of Internal Medicine and Chest Diseases, CHRU Brest, France.,Centre d'Investigation Clinique INSERM 1412, University of Brest, France
| | - Francis Couturaud
- Groupe d'Etude de la Thrombose de Bretagne Occidentale, University of Brest, Equipe d'Accueil 3878, Department of Internal Medicine and Chest Diseases, CHRU Brest, France.,Centre d'Investigation Clinique INSERM 1412, University of Brest, France
| | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, the Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, the Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, the Netherlands
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Acute Pulmonary Embolism in a Teenage Female - A Case Report. ACTA ACUST UNITED AC 2018; 4:101-104. [PMID: 30582003 PMCID: PMC6294988 DOI: 10.2478/jccm-2018-0015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 07/26/2018] [Indexed: 02/05/2023]
Abstract
Thrombophilia represents a tendency towards excessive blood clotting and the subsequent development of venous thromboembolism (VTE). VTE is a rare condition in children that comprises both deep venous thrombosis (DVT) and pulmonary embolism (PE). This paper reports the case of a 16-year-old girl, admitted to the Pediatrics Clinic No. 1, Tîrgu Mureș, Romania, for dyspnea, chest pain and loss of consciousness. Her personal history showed that she had had two orthopedic surgical interventions in infancy, two pregnancies, one spontaneous miscarriage and a recent caesarian section at 20 weeks of gestation for premature detachment of a normally positioned placenta associated with a deceased fetus. Laboratory tests showed increased levels of D-dimers. Angio-Computed Tomography (Angio-CT) showed multiple filling defects in both pulmonary arteries, establishing the diagnosis of PE. The laboratory tests were undertaken to assist in the diagnoses of a possible thrombophilia underlined a low level of antithrombin III. Antiphospholipid syndrome was ruled out and genetic tests revealed no specific mutation. Anticoagulant therapy was initiated with unfractionated heparin and afterwards subcutaneously low molecular heparin was prescribed for three months. Later it has been changed to oral therapy with acenocoumarol. The patient was discharged in good general status with the recommendation of life-long anticoagulation therapy. Thrombophilia is a significant risk factor for PE, and it must be ruled out in all cases of repeated miscarriage.
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28
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Friedman T, Winokur RS, Quencer KB, Madoff DC. Patient Assessment: Clinical Presentation, Imaging Diagnosis, Risk Stratification, and the Role of Pulmonary Embolism Response Team. Semin Intervent Radiol 2018; 35:116-121. [PMID: 29872247 DOI: 10.1055/s-0038-1642040] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Pulmonary embolism (PE) is currently the third leading cause of death and moreover is likely underdiagnosed. PE remains the most common preventable cause of hospital deaths in the United States, which may be attributable to its diagnostic challenges. Although difficult to diagnose, patient mortality rates are time-dependent, and thus, the suspicion and diagnosis of PE in a timely manner is imperative. Diagnosis based on several criteria which may dictate imaging workup as well as laboratory tests and clinical parameters are discussed. The evolution of treatment guidelines via various clinical trials and recommendations is outlined, setting the stage for the use of fibrinolytics, whether systemic or catheter directed. Treatment, including fibrinolytics, is predicated on patient triage into three large categories-massive, submassive, or low-risk PE. Additionally, a relatively new concept of a multidisciplinary team composed of several subspecialty experts known as the PE response team (PERT) is discussed. PERT's timely and unified recommendations have been shown to optimize care and decrease mortality while tailoring treatment to each individual afflicted by PE.
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Affiliation(s)
- Tamir Friedman
- Section of Interventional Radiology, Department of Radiology, Advanced Medical Imaging, Torrington, Connecticut
| | - Ronald S Winokur
- Section of Interventional Radiology, Department of Radiology, Weill Cornell/New York Presbyterian Hospital, New York, New York
| | - Keith B Quencer
- Section of Interventional Radiology, Department of Radiology, University of Utah, Salt Lake City, Utah
| | - David C Madoff
- Section of Interventional Radiology, Department of Radiology, Weill Cornell/New York Presbyterian Hospital, New York, New York
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29
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Kirsch J, Brown RKJ, Henry TS, Javidan-Nejad C, Jokerst C, Julsrud PR, Kanne JP, Kramer CM, Leipsic JA, Panchal KK, Ravenel JG, Shah AB, Mohammed TL, Woodard PK, Abbara S. ACR Appropriateness Criteria ® Acute Chest Pain-Suspected Pulmonary Embolism. J Am Coll Radiol 2018; 14:S2-S12. [PMID: 28473076 DOI: 10.1016/j.jacr.2017.02.027] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 02/06/2017] [Accepted: 02/07/2017] [Indexed: 01/08/2023]
Abstract
Pulmonary embolism (PE) remains a common and important clinical condition that cannot be accurately diagnosed on the basis of signs, symptoms, and history alone. The diagnosis of PE has been facilitated by technical advancements and multidetector CT pulmonary angiography, which is the major diagnostic modality currently used. Ventilation and perfusion scans remain largely accurate and useful in certain settings. Lower-extremity ultrasound can substitute by demonstrating deep vein thrombosis; however, if negative, further studies to exclude PE are indicated. In all cases, correlation with the clinical status, particularly with risk factors, improves not only the accuracy of diagnostic imaging but also overall utilization. Other diagnostic tests have limited roles. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Jacobo Kirsch
- Principal Author, Cleveland Clinic, Weston, Florida.
| | | | - Travis S Henry
- University of California San Francisco, San Francisco, California
| | - Cylen Javidan-Nejad
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri
| | | | | | - Jeffrey P Kanne
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Christopher M Kramer
- University of Virginia Health System, Charlottesville, Virginia; American College of Cardiology
| | | | | | - James G Ravenel
- Medical University of South Carolina, Charleston, South Carolina
| | - Amar B Shah
- Westchester Medical Center, Valhalla, New York
| | - Tan-Lucien Mohammed
- Specialty Chair, University of Florida College of Medicine, Gainesville, Florida
| | - Pamela K Woodard
- Specialty Chair, Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri
| | - Suhny Abbara
- Panel Chair, UT Southwestern Medical Center, Dallas, Texas
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30
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Abstract
Venous thromboembolism is a leading cause of maternal death. Because of the low absolute frequency of events, however, outcome-based clinical data are limited. Consequently, clinicians must additionally rely both on published guidelines and on extrapolation of data from studies focused on nonpregnant individuals. The diagnosis and treatment of deep vein thrombosis, pulmonary embolism, and cerebral vein and dural sinus thrombosis are complicated by pregnancy, and often require modifications to standard diagnostic and treatment algorithms outside of pregnancy. Treatment of VTE in pregnant women is in particular need of future research.
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31
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Should Dual-Energy Computed Tomography Pulmonary Angiography Replace Single-Energy Computed Tomography Pulmonary Angiography in Pregnant and Postpartum Patients? J Comput Assist Tomogr 2018; 42:25-32. [PMID: 28786905 DOI: 10.1097/rct.0000000000000655] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The study aims to compare single-energy (SE) and dual-energy (DE) computed tomography pulmonary angiography (CTPA) for evaluation of suspected pulmonary embolism in pregnant and postpartum patients. MATERIALS AND METHODS Our study included 59 CTPA performed in pregnant/postpartum women (study group) comprised of 38 SE-CTPA and 21 DE-CTPA. The control group of 21 age- and weight-matched nonpregnant/nonpostpartum women underwent DE-CTPA. Two radiologists assessed pulmonary arterial enhancement, image quality, and artifacts. κ Test and analysis of variance were performed. RESULTS Fourteen of 38 pregnant/postpartum women (37%) had suboptimal SE-CTPA compared with just 10% (2/21) suboptimal DE-CTPA studies (P = 0.02). Mean Hounsfield unit (HU) in the pulmonary trunk was 550 ± 68 HU in the DE-CTPA pregnant/postpartum group and 245 ± 12 HU in the SE-CTPA (P < 0.001). The mean volume computed tomography dose index in the pregnant/postpartum patients for DE-CTPA and SE-CTPA were 9 ± 2 and 19 ± 8 mGy, respectively (P < 0.001). CONCLUSIONS Dual-energy CTPA substantially increased arterial enhancement for evaluation of pulmonary embolism in pregnant and postpartum women compared with SE-CTPA.
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32
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Sheen JJ, Haramati LB, Natenzon A, Ma H, Tropper P, Bader AS, Freeman LM, Bernstein PS, Moadel RM. Performance of Low-Dose Perfusion Scintigraphy and CT Pulmonary Angiography for Pulmonary Embolism in Pregnancy. Chest 2017; 153:152-160. [PMID: 28823756 DOI: 10.1016/j.chest.2017.08.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 07/06/2017] [Accepted: 08/01/2017] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND The symptoms of normal pregnancy overlap those of pulmonary embolism (PE). Limited literature suggests that low-dose perfusion scanning (LDQ), which yields lower maternal-fetal radiation exposure than CT pulmonary angiography (CTPA), performs well in excluding PE in pregnant patients. METHODS We performed a retrospective cohort study of sequential pregnant women who underwent imaging for PE with LDQ or CTPA between 2008 and 2013 at Montefiore Medical Center. Our practice recommends LDQ for patients with negative results on chest radiographs. Patients were categorized according to initial imaging modality, and a subgroup analysis was performed in patients with asthma. The primary outcome was the negative predictive value (NPV) of imaging determined by VTE diagnosis within 90 days. RESULTS Of 322 pregnant women (mean age, 27.3 ± 6.3 years), initial imaging was positive for PE in 2.7% (6 of 225) of LDQs and 4.1% (4 of 97) of CTPAs, negative in 88.0% (198 of 225) of LDQs and 86.6% (84 of 97) of CTPAs, and indeterminate/nondiagnostic in 9.3% (21 of 225) of LDQs and 9.3% (9 of 97) of CTPAs (P = .79). Ten patients (3.1%) were treated for PE. The NPV was 100% for LDQ and 97.5% for CTPA. Subgroup analysis of patients with asthma (23.9% of this population) revealed a high likelihood of a negative study in the LDQ and CTPA groups (74.1% and 87.0%, respectively) and 100% NPV for both modalities. CONCLUSIONS PE is an uncommon diagnosis in pregnancy. LDQ and CTPA perform well, with less maternal-fetal radiation exposure with LDQ. Therefore, when available, LDQ is a reasonable first-choice modality for suspected PE in pregnant women with a negative result on chest radiograph.
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Affiliation(s)
- Jean-Ju Sheen
- Department of Obstetrics and Gynecology & Women's Health, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY
| | - Linda B Haramati
- Department of Radiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY; Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY
| | - Anna Natenzon
- Department of Obstetrics and Gynecology & Women's Health, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY
| | - Hong Ma
- Department of Radiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY
| | - Pamela Tropper
- Department of Obstetrics and Gynecology & Women's Health, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY
| | - Anna S Bader
- Department of Radiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY
| | - Leonard M Freeman
- Department of Radiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY
| | - Peter S Bernstein
- Department of Obstetrics and Gynecology & Women's Health, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY
| | - Renee M Moadel
- Department of Radiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY.
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33
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Armstrong L, Gleeson F, Mackillop L, Mutch S, Beale A. Survey of UK imaging practice for the investigation of pulmonary embolism in pregnancy. Clin Radiol 2017; 72:696-701. [DOI: 10.1016/j.crad.2017.03.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 03/13/2017] [Accepted: 03/30/2017] [Indexed: 01/26/2023]
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"Pulmonary embolism diagnostics of pregnant patients: What is the recommended clinical pathway considering the clinical value and associated radiation risks of available imaging tests?". Phys Med 2017; 43:178-185. [PMID: 28760505 DOI: 10.1016/j.ejmp.2017.07.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 07/13/2017] [Accepted: 07/22/2017] [Indexed: 11/20/2022] Open
Abstract
Pulmonary embolism (PE) during pregnancy remains the leading preventable cause of maternal morbidity and mortality in the developed countries. Diagnosis of PE in pregnant patients is a challenging clinical problem, since pregnancy-related physiologic changes can mimic signs and symptoms of PE. Patient mismanagement may result into unjustified anticoagulant treatment or unnecessary imaging tests involving contrast-related or/and radiation-related risks for both the expectant mother and embryo/fetus. On the other hand, missing or delaying diagnosis of PE could lead to life-threatening conditions for both the mother and the embryo/fetus. Thus, a timely and accurate diagnostic approach is required for the optimal management of pregnant patients with suspected PE. Aim of the current review is to discuss a pregnancy-specific clinical pathway for the early diagnosis of PE with non-ionizing radiation- and ionizing radiation-based imaging modalities taking into account previously reported data on diagnostic value of available imaging tests, and radiation related concerns.
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35
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Wan T, Skeith L, Karovitch A, Rodger M, Le Gal G. Guidance for the diagnosis of pulmonary embolism during pregnancy: Consensus and controversies. Thromb Res 2017; 157:23-28. [PMID: 28686913 DOI: 10.1016/j.thromres.2017.06.025] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 06/19/2017] [Accepted: 06/20/2017] [Indexed: 12/20/2022]
Abstract
Pulmonary embolism (PE) is one of the leading causes of maternal mortality despite a low incidence of PE during pregnancy. Several challenges surround the diagnosis of PE in pregnant women and the existing clinical guidelines provide weak recommendations on selecting the appropriate investigations for suspected PE in pregnancy. The purpose of this narrative review is to compare and contrast the recommendations of current clinical guidelines and review the evidence underpinning the recommendations on the evaluation of suspected PE in pregnancy. Consensus and controversies, knowledge gaps and areas requiring further research will be highlighted.
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Affiliation(s)
- Tony Wan
- Division of Hematology, Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Leslie Skeith
- Division of Hematology, Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Alan Karovitch
- Division of General Internal Medicine, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Marc Rodger
- Division of Hematology, Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Grégoire Le Gal
- Division of Hematology, Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada.
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36
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Tromeur C, van der Pol LM, Klok FA, Couturaud F, Huisman MV. Pitfalls in the diagnostic management of pulmonary embolism in pregnancy. Thromb Res 2017; 151 Suppl 1:S86-S91. [PMID: 28262243 DOI: 10.1016/s0049-3848(17)30075-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Women are at increased risk of venous thromboembolism (VTE) during pregnancy and VTE remains one of the main causes of maternal mortality in developed countries (Konstantinides SV, et al. Eur Heart J 2014; 35(43):3033-69, 69a-69k). Although an accurate diagnosis of acute pulmonary embolism (PE) in pregnant patients is thus of crucial importance, the diagnostic management of suspected PE is challenging for this specific patient category. As D-dimer levels increase physiologically throughout pregnancy, the optimal D-dimer threshold to rule out PE during pregnancy remains unknown. Available clinical decision rules, such as the Wells score and the revised Geneva rule, have not been evaluated in pregnant patients. Also, although ventilation-perfusion (V-Q) lung scan and computed tomography pulmonary angiography (CTPA) can be used in the pregnant population, both modalities have disadvantages of radiation exposure to both mother and foetus. Because of these uncertainties, clinical guidelines provide contradicting recommendations with weak levels of evidence. In this review, we illustrate these dilemmas and provide practice recommendation for the diagnostic management of suspected PE in pregnancy using two real-life patient cases.
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Affiliation(s)
- Cécile Tromeur
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands; Groupe d'Etude de la Thrombose de Bretagne Occidentale, Equipe d'Accueil 3878, Department of Internal Medicine and Chest Diseases, Brest, France; Centre d'Investigation Clinique INSERM 1412, Groupe d'Investigation et de Recherche Clinique, Brittany University of Brest, Brest, France
| | - Liselotte M van der Pol
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Francis Couturaud
- Groupe d'Etude de la Thrombose de Bretagne Occidentale, Equipe d'Accueil 3878, Department of Internal Medicine and Chest Diseases, Brest, France; Centre d'Investigation Clinique INSERM 1412, Groupe d'Investigation et de Recherche Clinique, Brittany University of Brest, Brest, France
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands.
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Zhou XY, Jeffris KE, Yu EY, Zheng B, Goodwill PW, Nahid P, Conolly SM. First in vivo magnetic particle imaging of lung perfusion in rats. Phys Med Biol 2017; 62:3510-3522. [PMID: 28218614 DOI: 10.1088/1361-6560/aa616c] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Pulmonary embolism (PE), along with the closely related condition of deep vein thrombosis, affect an estimated 600 000 patients in the US per year. Untreated, PE carries a mortality rate of 30%. Because many patients experience mild or non-specific symptoms, imaging studies are necessary for definitive diagnosis of PE. Iodinated CT pulmonary angiography is recommended for most patients, while nuclear medicine-based ventilation/perfusion (V/Q) scans are reserved for patients in whom the use of iodine is contraindicated. Magnetic particle imaging (MPI) is an emerging tracer imaging modality with high image contrast (no tissue background signal) and sensitivity to superparamagnetic iron oxide (SPIO) tracer. Importantly, unlike CT or nuclear medicine, MPI uses no ionizing radiation. Further, MPI is not derived from magnetic resonance imaging (MRI); MPI directly images SPIO tracers via their strong electronic magnetization, enabling deep imaging of anatomy including within the lungs, which is very challenging with MRI. Here, the first high-contrast in vivo MPI lung perfusion images of rats are shown using a novel lung perfusion agent, MAA-SPIOs.
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Affiliation(s)
- Xinyi Y Zhou
- UC Berkeley-UCSF Graduate Program in Bioengineering, Berkeley, CA 94720, United States of America. Department of Bioengineering, University of California Berkeley, Berkeley, CA 94720, United States of America
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van Mens TE, Scheres LJJ, de Jong PG, Leeflang MMG, Nijkeuter M, Middeldorp S. Imaging for the exclusion of pulmonary embolism in pregnancy. Cochrane Database Syst Rev 2017; 1:CD011053. [PMID: 28124411 PMCID: PMC6464730 DOI: 10.1002/14651858.cd011053.pub2] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Pulmonary embolism is a leading cause of pregnancy-related death. An accurate diagnosis in pregnant patients is crucial to prevent untreated pulmonary embolism as well as unnecessary anticoagulant treatment and future preventive measures. Applied imaging techniques might perform differently in these younger patients with less comorbidity and altered physiology, who largely have been excluded from diagnostic studies. OBJECTIVES To determine the diagnostic accuracy of computed tomography pulmonary angiography (CTPA), lung scintigraphy and magnetic resonance angiography (MRA) for the diagnosis of pulmonary embolism during pregnancy. SEARCH METHODS We searched MEDLINE and Embase until July 2015. We used included studies as seeds in citations searches and in 'find similar' functions and searched reference lists. We approached experts in the field to help us identify non-indexed studies. SELECTION CRITERIA We included consecutive series of pregnant patients suspected of pulmonary embolism who had undergone one of the index tests (computed tomography (CT) pulmonary angiography, lung scintigraphy or MRA) and clinical follow-up or pulmonary angiography as a reference test. DATA COLLECTION AND ANALYSIS Two review authors performed data extraction and quality assessment. We contacted investigators of potentially eligible studies to obtain missing information. In the primary analysis, we regarded inconclusive index test results as a negative reference test, and treatment for pulmonary embolism after an inconclusive index test as a positive reference test. MAIN RESULTS We included 11 studies (four CTPA, five lung scintigraphy, two both) with a total of 695 CTPA and 665 lung scintigraphy results. Lung scintigraphy was applied by different techniques. No MRA studies matched our inclusion criteria.Overall, risk of bias and concerns regarding applicability were high in all studies as judged in light of the review research question, as was heterogeneity in study methods. We did not undertake meta-analysis. All studies used clinical follow-up as a reference standard, none in a manner that enabled reliable identification of false positives. Sensitivity and negative predictive value were therefore the only valid test accuracy measures.The median negative predictive value for CTPA was 100% (range 96% to 100%). Median sensitivity was 83% (range 0% to 100%).The median negative predictive value for lung scintigraphy was 100% (range 99% to 100%). Median sensitivity was 100% (range 0% to 100%).The median frequency of inconclusive results was 5.9% (range 0.9% to 36%) for CTPA and 4.0% (range 0% to 23%) for lung scintigraphy. The overall median prevalence of pulmonary embolism was 3.3% (range 0.0% to 8.7%). AUTHORS' CONCLUSIONS Both CTPA and lung scintigraphy seem appropriate for exclusion of pulmonary embolism during pregnancy. However, the quality of the evidence mandates cautious adoption of this conclusion. Important limitations included poor reference standards, necessary assumptions in the analysis regarding inconclusive test results and the inherent inability of included studies to identify false positives. It is unclear which test has the highest accuracy. There is a need for direct comparisons between diagnostic methods, including MR, in prospective randomized diagnostic studies.
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Affiliation(s)
- Thijs E van Mens
- Academic Medical CenterDepartment of Vascular MedicineMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Luuk JJ Scheres
- Academic Medical CenterDepartment of Vascular MedicineMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Paulien G de Jong
- Academic Medical CenterDepartment of Vascular MedicineMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Mariska MG Leeflang
- Academic Medical Center, University of AmsterdamDepartment of Clinical Epidemiology, Biostatistics and BioinformaticsP.O. Box 22700AmsterdamNetherlands1100 DE
| | - Mathilde Nijkeuter
- Academic Medical CenterDepartment of Vascular MedicineMeibergdreef 9AmsterdamNetherlands1105 AZ
- University Medical Centre UtrechtDepartment of Internal MedicineHeidelberglaan 100UtrechtNetherlands3584 CX
| | - Saskia Middeldorp
- Academic Medical CenterDepartment of Vascular MedicineMeibergdreef 9AmsterdamNetherlands1105 AZ
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McLean K, Cushman M. Venous thromboembolism and stroke in pregnancy. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2016; 2016:243-250. [PMID: 27913487 PMCID: PMC6142428 DOI: 10.1182/asheducation-2016.1.243] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Pregnancy and the postpartum period substantially increase the risk for thrombotic events. Although the absolute risk for thrombosis is low, these events comprise a significant portion of maternal morbidity and mortality. The vast majority of such events are venous, although the risk for ischemic stroke also appears to be increased in pregnancy. This review will explore the overlapping and unique risk factors for venous and arterial thrombosis in pregnancy. Diagnosis and prevention will be discussed, and treatment will be briefly touched on. The benefit of using a multidisciplinary model in caring for pregnant women who have had a thrombotic event or who are at increased risk for thrombosis is a major focus of the review. Using the experience of our own Hematology and Obstetrics/Maternal Fetal Medicine shared care model, we discuss specific examples of when the use of such an approach is particularly valuable.
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Affiliation(s)
- Kelley McLean
- Department of Obstetrics, Gynecology and Reproductive Sciences
| | - Mary Cushman
- Department of Medicine, and
- Department of Pathology, Larner College of Medicine at the University of Vermont, Burlington, VT
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Yazdani M, Lau CT, Lempel JK, Yadav R, El-Sherief AH, Azok JT, Renapurkar RD. Historical Evolution of Imaging Techniques for the Evaluation of Pulmonary Embolism. Radiographics 2016; 35:1245-62. [PMID: 26172362 DOI: 10.1148/rg.2015140280] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
As we celebrate the 100th anniversary of the founding of the Radiological Society of North America (RSNA), it seems fitting to look back at the major accomplishments of the radiology community in the diagnosis of pulmonary embolism. Few diseases have so consistently captured the attention of the medical community. Since the first description of pulmonary embolism by Virchow in the 1850s, clinicians have struggled to reach a timely diagnosis of this common condition because of its nonspecific and often confusing clinical picture. As imaging tests started to gain importance in the 1900s, the approach to diagnosing pulmonary embolism also began to change. Rapid improvements in angiography, ventilation-perfusion imaging, and cross-sectional imaging modalities such as computed tomography (CT) and magnetic resonance imaging have constantly forced health care professionals to rethink how they diagnose pulmonary embolism. Needless to say, the way pulmonary embolism is diagnosed today is distinctly different from how it was diagnosed in Virchow's era; and imaging, particularly CT, now forms the cornerstone of diagnostic evaluation. Currently, radiology offers a variety of tests that are fast and accurate and can provide anatomic and functional information, thus allowing early diagnosis and triage of cases. This review provides a historical journey into the evolution of these imaging tests and highlights some of the major breakthroughs achieved by the radiology community and RSNA in this process. Also highlighted are areas of ongoing research and development in this field of imaging as radiologists seek to combat some of the newer challenges faced by modern medicine, such as rising health care costs and radiation dose hazards.
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Affiliation(s)
- Milad Yazdani
- From the Sections of Thoracic Imaging (M.Y., C.T.L., J.K.L., R.Y., A.H.E., J.T.Z., R.D.R.) and Nuclear Medicine (R.Y., R.D.R.), Imaging Institute, Thoracic Imaging L10, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195
| | - Charles T Lau
- From the Sections of Thoracic Imaging (M.Y., C.T.L., J.K.L., R.Y., A.H.E., J.T.Z., R.D.R.) and Nuclear Medicine (R.Y., R.D.R.), Imaging Institute, Thoracic Imaging L10, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195
| | - Jason K Lempel
- From the Sections of Thoracic Imaging (M.Y., C.T.L., J.K.L., R.Y., A.H.E., J.T.Z., R.D.R.) and Nuclear Medicine (R.Y., R.D.R.), Imaging Institute, Thoracic Imaging L10, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195
| | - Ruchi Yadav
- From the Sections of Thoracic Imaging (M.Y., C.T.L., J.K.L., R.Y., A.H.E., J.T.Z., R.D.R.) and Nuclear Medicine (R.Y., R.D.R.), Imaging Institute, Thoracic Imaging L10, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195
| | - Ahmed H El-Sherief
- From the Sections of Thoracic Imaging (M.Y., C.T.L., J.K.L., R.Y., A.H.E., J.T.Z., R.D.R.) and Nuclear Medicine (R.Y., R.D.R.), Imaging Institute, Thoracic Imaging L10, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195
| | - Joseph T Azok
- From the Sections of Thoracic Imaging (M.Y., C.T.L., J.K.L., R.Y., A.H.E., J.T.Z., R.D.R.) and Nuclear Medicine (R.Y., R.D.R.), Imaging Institute, Thoracic Imaging L10, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195
| | - Rahul D Renapurkar
- From the Sections of Thoracic Imaging (M.Y., C.T.L., J.K.L., R.Y., A.H.E., J.T.Z., R.D.R.) and Nuclear Medicine (R.Y., R.D.R.), Imaging Institute, Thoracic Imaging L10, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195
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Grüning T, Mingo RE, Gosling MG, Farrell SL, Drake BE, Loader RJ, Riordan RD. Diagnosing venous thromboembolism in pregnancy. Br J Radiol 2016; 89:20160021. [PMID: 27055494 DOI: 10.1259/bjr.20160021] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE We report the imaging outcomes of all pregnant patients referred for suspected thromboembolism over a 43-month period. METHODS We identified 168 patients who underwent ventilation/perfusion (VQ) single-photon emission CT (SPECT), CT pulmonary angiography (CTPA) or a Doppler ultrasound scan of the lower legs, as well as a control group of 89 non-pregnant age- and sex-matched patients who underwent VQ SPECT during the same period. Imaging outcomes were recorded, and radiation doses were calculated for individual patients. RESULTS VQ SPECT and CTPA were equally likely to diagnose pulmonary embolism (PE) in about one patient out of every seven patients investigated. One in three CTPA scans was of suboptimal quality. A Doppler ultrasound examination of the legs will find deep venous thrombosis much less often, in about 1 patient out of every 15 patients investigated. The prevalence of PE in pregnant patients (as diagnosed by VQ SPECT) was similar to that in the non-pregnant, age- and sex-matched control group. The effective dose and the absorbed radiation dose to the maternal breast were lower with VQ SPECT. The foetal dose is comparable for both VQ SPECT and CTPA. CONCLUSION VQ SPECT and CTPA provide a similar diagnostic yield for diagnosing PE during pregnancy, but VQ SPECT does so with a lower radiation dose to the mother (effective dose and breast dose). ADVANCES IN KNOWLEDGE Ours is the first report of the diagnostic performance of VQ SPECT, rather than planar VQ scans, in pregnancy in a routine clinical setting.
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Affiliation(s)
- Thomas Grüning
- 1 Department of Nuclear Medicine, Derriford Hospital, Plymouth, UK
| | - Rebecca E Mingo
- 1 Department of Nuclear Medicine, Derriford Hospital, Plymouth, UK
| | - Matthew G Gosling
- 2 Department of Clinical and Radiation Physics, Derriford Hospital, Plymouth, UK
| | - Sally L Farrell
- 1 Department of Nuclear Medicine, Derriford Hospital, Plymouth, UK
| | - Brent E Drake
- 1 Department of Nuclear Medicine, Derriford Hospital, Plymouth, UK
| | - Robert J Loader
- 2 Department of Clinical and Radiation Physics, Derriford Hospital, Plymouth, UK
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Abstract
Abstract
Because the clinical diagnosis of deep-vein thrombosis and pulmonary embolism is nonspecific, integrated diagnostic approaches for patients with suspected venous thromboembolism have been developed over the years, involving both non-invasive bedside tools (clinical decision rules and D-dimer blood tests) for patients with low pretest probability and diagnostic techniques (compression ultrasound for deep-vein thrombosis and computed tomography pulmonary angiography for pulmonary embolism) for those with a high pretest probability. This combination has led to standardized diagnostic algorithms with proven safety for excluding venous thrombotic disease. At the same time, it has become apparent that, as a result of the natural history of venous thrombosis, there are special patient populations in which the current standard diagnostic algorithms are not sufficient. In this review, we present 3 evidence-based patient cases to underline recent developments in the imaging diagnosis of venous thromboembolism.
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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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Abstract
PURPOSE OF REVIEW This review provides a concise and complete overview of diagnostic work-up and treatment of venous thromboembolism in pregnancy, with attention to recent research developments and recent applicable guidelines. This may be useful for all the players of the multidisciplinary interaction needed in this disease management, namely cardiologists and gynecological/obstetric teams. RECENT FINDINGS Venous thromboembolism is, in the developed world, a major cause of maternal morbidity and mortality during pregnancy or early after delivery, with a reported incidence ranging from 0.49 to 2.0 events per 1000 deliveries. It is a particularly challenging issue and there is no common consensus on the major themes of this condition. Diagnostic options, prophylaxis and management, in the antenatal, childbirth and postnatal periods, are carefully analyzed in the light of the most recent published data. Besides, old and recent knowledge must be seen through the clinician's skilled and watchful eyes, deciding on a case-to-case and actively contributing in reducing pregnancy-related morbidity. SUMMARY Although there is an ongoing debate on various aspects of this condition and there is a paucity of high-quality studies, this review attempts to simplify the complex aspects of joining safety and efficacy in diagnosing and treating a possible two-people life-threatening disease.
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Marshall AL. Diagnosis, Treatment, and Prevention of Venous Thromboembolism in Pregnancy. Postgrad Med 2015; 126:25-34. [DOI: 10.3810/pgm.2014.11.2830] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Jordan EJ, Godelman A, Levsky JM, Zalta B, Haramati LB. CT pulmonary angiography in pregnant and postpartum women: low yield, high dose. Clin Imaging 2015; 39:251-3. [DOI: 10.1016/j.clinimag.2014.11.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Revised: 10/08/2014] [Accepted: 11/10/2014] [Indexed: 12/01/2022]
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Huisman MV, Klok FA. Current challenges in diagnostic imaging of venous thromboembolism. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2015; 2015:202-209. [PMID: 26637722 DOI: 10.1182/asheducation-2015.1.202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Because the clinical diagnosis of deep-vein thrombosis and pulmonary embolism is nonspecific, integrated diagnostic approaches for patients with suspected venous thromboembolism have been developed over the years, involving both non-invasive bedside tools (clinical decision rules and D-dimer blood tests) for patients with low pretest probability and diagnostic techniques (compression ultrasound for deep-vein thrombosis and computed tomography pulmonary angiography for pulmonary embolism) for those with a high pretest probability. This combination has led to standardized diagnostic algorithms with proven safety for excluding venous thrombotic disease. At the same time, it has become apparent that, as a result of the natural history of venous thrombosis, there are special patient populations in which the current standard diagnostic algorithms are not sufficient. In this review, we present 3 evidence-based patient cases to underline recent developments in the imaging diagnosis of venous thromboembolism.
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Affiliation(s)
- Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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Konstantinides SV, Torbicki A, Agnelli G, Danchin N, Fitzmaurice D, Galiè N, Gibbs JSR, Huisman MV, Humbert M, Kucher N, Lang I, Lankeit M, Lekakis J, Maack C, Mayer E, Meneveau N, Perrier A, Pruszczyk P, Rasmussen LH, Schindler TH, Svitil P, Vonk Noordegraaf A, Zamorano JL, Zompatori M. 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J 2014; 35:3033-69, 3069a-3069k. [PMID: 25173341 DOI: 10.1093/eurheartj/ehu283] [Citation(s) in RCA: 1856] [Impact Index Per Article: 185.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Abstract
BACKGROUND Pulmonary embolism (PE) can be a life-threatening emergency. Accurate diagnostic techniques and patient-specific management strategies are necessary to ensure favorable clinical outcomes. METHODS Relevant guidelines, articles, reviews, and abstracts were identified using a narrative approach in PubMed/MEDLINE, Google Scholar, clinicaltrials.gov and nice.org.uk. English-language articles published in 2000-2014 were initially identified using the search terms: novel OAC, pulmonary embolism, venous thromboembolism, diagnosis, treatment, rivaroxaban, apixaban, dabigatran, and edoxaban. The initial literature search was supported by a 'snowballing' style literature search, and relevant articles were included based on a professional judgment of relevance. SCOPE We discuss the diagnosis of PE and the categorization of risk for subgroups, which may assist with making treatment decisions. We review current guidance on acute and long-term treatment, possible limitations of traditional anticoagulant therapy, and the development of direct oral anticoagulants, which may significantly alter the management of patients with PE. Finally, we discuss special considerations in high-risk and hard-to-treat subpopulations that may benefit from the improved benefit-risk profile offered by these newer agents. CONCLUSIONS The direct oral anticoagulants may overcome several of the limitations associated with traditional anticoagulant therapy, potentially improving the standard of care for PE patients, including high-risk and hard-to-manage subgroups.
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Affiliation(s)
- Robert J Walter
- Walter Reed National Military Medical Center , Bethesda, MD , USA
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Goodacre S, Nelson-Piercy C, Hunt B, Chan WS. When should we use diagnostic imaging to investigate for pulmonary embolism in pregnant and postpartum women? Emerg Med J 2014; 32:78-82. [DOI: 10.1136/emermed-2014-203871] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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