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Squizzato A, Venturini A, Pelitti V, Bellini B, Bernasconi M, Depalo T, Corso A, Riva N. Diagnostic Accuracy of V/Q and Q SPECT/CT in Patients with Suspected Acute Pulmonary Embolism: A Systematic Review and Meta-analysis. Thromb Haemost 2023. [PMID: 36423623 DOI: 10.1055/a-1986-8878] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Computed tomography (CT) pulmonary angiography has simplified the diagnostic approach to patients with clinically suspected acute pulmonary embolism (PE), but alternative imaging tests are still advocated. We aimed to systematically assess the diagnostic accuracy of ventilation/perfusion (V/Q) and Q single-photon emission CT combined with low-dose CT (SPECT/CT) for PE diagnosis. METHODS Studies evaluating the diagnostic accuracy of SPECT/CT for the diagnosis of acute PE were systematically searched in MEDLINE and EMBASE databases (up to August 2022). The QUADAS-2 tool was used for risk-of-bias assessment of the primary studies. A bivariate random-effects regression approach was used for summary estimates of both sensitivity and specificity. The PROSPERO registration number is CRD42021276538. RESULTS Eight studies, for a total of 1,086 patients, were included. The risk of bias of all included studies was high. The weighted mean prevalence of PE was 27.1% at the random-effects model. The SPECT/CT bivariate weighted mean sensitivity was 96% (95% confidence interval [CI]: 93-98%), with a bivariate weighted mean specificity of 95% (95% CI: 90-97%). At subgroup analysis, for V/Q SPECT/CT bivariate weighted mean sensitivity and specificity were 96% (95% CI: 89-98%) and 96% (95% CI: 91-99%), while for Q SPECT/CT they were 96% (95% CI: 92-98%) and 84% (95% CI: 66-93%), respectively. CONCLUSIONS V/Q SPECT/CT has high sensitivity and specificity for the diagnosis of acute PE, meanwhile Q SPECT/CT has high sensitivity but limited specificity for the diagnosis of PE. Management studies will conclusively ascertain the actual role of SPECT/CT in the diagnostic workup of patients with suspected acute PE.
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Affiliation(s)
- Alessandro Squizzato
- Research Center on Thromboembolic Disorders and Antithrombotic Therapies, ASST Lariana, University of Insubria, Como, Italy
| | - Alice Venturini
- Internal Medicine Residency Program, School of Medicine, University of Insubria, Varese and Como, Italy
| | - Valentina Pelitti
- Internal Medicine Residency Program, School of Medicine, University of Insubria, Varese and Como, Italy
| | - Beatrice Bellini
- Internal Medicine Residency Program, School of Medicine, University of Insubria, Varese and Como, Italy
| | | | - Tommaso Depalo
- Nuclear Medicine Unit, 'Sant'Anna' Hospital, ASST Lariana, Como, Italy
| | - Angelo Corso
- Nuclear Medicine Unit, 'Sant'Anna' Hospital, ASST Lariana, Como, Italy
| | - Nicoletta Riva
- Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta
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2
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Prevalence, Treatment, and Prognosis of Tumor Thrombi in Renal Cell Carcinoma. JACC: CARDIOONCOLOGY 2022; 4:522-531. [DOI: 10.1016/j.jaccao.2022.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 07/21/2022] [Indexed: 11/17/2022]
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3
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Boon GJAM, Jairam PM, Groot GMC, van Rooden CJ, Ende-Verhaar YM, Beenen LFM, Kroft LJM, Bogaard HJ, Huisman MV, Symersky P, Vonk Noordegraaf A, Meijboom LJ, Klok FA. Identification of chronic thromboembolic pulmonary hypertension on CTPAs performed for diagnosing acute pulmonary embolism depending on level of expertise. Eur J Intern Med 2021; 93:64-70. [PMID: 34294517 DOI: 10.1016/j.ejim.2021.07.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/30/2021] [Accepted: 07/08/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Expert reading often reveals radiological signs of chronic thromboembolic pulmonary hypertension (CTEPH) or chronic PE on computed tomography pulmonary angiography (CTPA) performed at the time of acute pulmonary embolism (PE) presentation preceding CTEPH. Little is known about the accuracy and reproducibility of CTPA reading by radiologists in training in this setting. OBJECTIVES To evaluate 1) whether signs of CTEPH or chronic PE are routinely reported on CTPA for suspected PE; and 2) whether CTEPH-non-expert readers achieve comparable predictive accuracy to CTEPH-expert radiologists after dedicated instruction. METHODS Original reports of CTPAs demonstrating acute PE in 50 patients whom ultimately developed CTEPH, and those of 50 PE who did not, were screened for documented signs of CTEPH. All scans were re-assessed by three CTEPH-expert readers and two CTEPH-non-expert readers (blinded and independently) for predefined signs and overall presence of CTEPH. RESULTS Signs of chronic PE were mentioned in the original reports of 14/50 cases (28%), while CTEPH-expert radiologists had recognized 44/50 (88%). Using a standardized definition (≥3 predefined radiological signs), moderate-to-good agreement was reached between CTEPH-non-expert readers and the experts' consensus (k-statistics 0.46; 0.61) at slightly lower sensitivities. The CTEPH-non-expert readers had moderate agreement on the presence of CTEPH (κ-statistic 0.38), but both correctly identified most cases (80% and 88%, respectively). CONCLUSIONS Concomitant signs of CTEPH were poorly documented in daily practice, while most CTEPH patients were identified by CTEPH-non-expert readers after dedicated instruction. These findings underline the feasibility of achieving earlier CTEPH diagnosis by assessing CTPAs more attentively.
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Affiliation(s)
- Gudula J A M Boon
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
| | - Pushpa M Jairam
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Gerie M C Groot
- Department of Radiology, Medical Center Gelderse Vallei, Ede, the Netherlands
| | | | - Yvonne M Ende-Verhaar
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Ludo F M Beenen
- Department of Radiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Harm Jan Bogaard
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Petr Symersky
- Department of Cardiothoracic Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Anton Vonk Noordegraaf
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Lilian J Meijboom
- Department of Radiology and Nuclear Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
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4
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Boon GJAM, Janssen SMJ, Barco S, Bogaard HJ, Ghanima W, Kroft LJM, Meijboom LJ, Ninaber MK, Nossent EJ, Spruit MA, Symersky P, Vliegen HW, Noordegraaf AV, Huisman MV, Siegerink B, Abbink JJ, Klok FA. Efficacy and safety of a 12-week outpatient pulmonary rehabilitation program in Post-PE Syndrome. Thromb Res 2021; 206:66-75. [PMID: 34419865 DOI: 10.1016/j.thromres.2021.08.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 08/11/2021] [Accepted: 08/12/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND The Post-Pulmonary Embolism Syndrome (PPES) comprises heterogeneous entities, including chronic thromboembolic disease with/without pulmonary hypertension (CTEPH/CTEPD), and deconditioning. OBJECTIVES To assess underlying physiological determinants of PPES, and efficacy and safety of rehabilitation training in these patients. METHODS 56 consecutive PE patients with persistent dyspnea and/or functional limitations despite ≥3 months of anticoagulation underwent standardized diagnostic work-up including exercise testing as part of routine practice. All diagnostic (imaging and cardiopulmonary function) tests were interpreted by a core group of experienced clinicians. A subgroup of patients without CTEPH or other treatable conditions was referred for a 12-week personalized rehabilitation program, studying changes in physical condition and patient-reported outcome measures. RESULTS Persistent vascular occlusions were observed in 21/56 patients (38%) and CTEPH was confirmed in ten (18%). Regarding those without CTEPH, impaired cardiopulmonary responses were evident in 18/39 patients with available CPET data (46%), unrelated to chronic thrombi. Rehabilitation was completed by 27 patients after excluding 29 (patients with CTEPH or treatable comorbidities, refusal, ineligibility, or training elsewhere). Training intensity, PE-specific quality of life (PEmb-QoL) and fatigue (CIS) improved with a median difference of 20 W (p = 0.001), 3.9 points (p < 0.001) and 16 points (p = 0.003), respectively. Functional status (Post-VTE Functional Status Scale) improved ≥1 grade in 18 (67%) patients, and declined in one (3.7%). CONCLUSIONS Our findings suggest that abnormal cardiopulmonary responses to exercise are common in patients with PPES and are not limited to those with chronic thrombi. Offering pulmonary rehabilitation to patients not treated otherwise seems safe and promising.
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Affiliation(s)
- Gudula J A M Boon
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Stefano Barco
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany; Clinic of Angiology, University Hospital of Zurich, Zurich, Switzerland
| | - Harm Jan Bogaard
- Department of Pulmonology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Waleed Ghanima
- Departments of Oncology, Medicine and Research, Østfold Hospital Trust, Kalnes, Norway; Institute of Clinical Research, University of Oslo, Oslo, Norway
| | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Lilian J Meijboom
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Maarten K Ninaber
- Department of Pulmonology, Leiden University Medical Center, Leiden, the Netherlands
| | - Esther J Nossent
- Department of Pulmonology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Martijn A Spruit
- Department of Research and Development, CIRO+, Horn, the Netherlands; NUTRIM School of Nutrition and Translational Research in Metabolism, Faculty of Health, Medicine and Life Sciences, Maastricht, the Netherlands; Department of Respiratory Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Petr Symersky
- Department of Cardiac Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Hubert W Vliegen
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Anton Vonk Noordegraaf
- Department of Pulmonology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Menno V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Bob Siegerink
- Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
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5
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De Pooter N, Brionne-François M, Smahi M, Abecassis L, Toulon P. Age-adjusted D-dimer cut-off levels to rule out venous thromboembolism in patients with non-high pre-test probability: Clinical performance and cost-effectiveness analysis. J Thromb Haemost 2021; 19:1271-1282. [PMID: 33638267 DOI: 10.1111/jth.15278] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 02/22/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND As aging was found to be associated with increased D-dimer levels, the question arose whether D-dimer measurement was useful in the diagnostic strategy of venous thromboembolism (VTE) in elderly patients. AIM OF THE STUDY To compare retrospectively the performance of six diagnostic strategies based on the three-level Wells scores and various cut-off levels for D-dimer, evaluated using the HemosIL D-Dimer HS 500 assay, in a derivation cohort of 644 outpatients with non-high pretest probability (PTP) of VTE. The clinical usefulness of the best-performing strategy was then confirmed in a multicenter validation study involving 1255 consecutive outpatients with non-high PTP. RESULTS The diagnostic strategy based on the age-adjusted cut-off level calculated by multiplying the patient's age by 10 above 50 years was found to perform the best in the derivation study with a better sensitivity-to-specificity ratio than the conventional strategy based on the fixed cut-off level (500 ng/ml), a higher specificity and a negative predictive value (NPV) above 99%. Such an increase in test specificity was confirmed in the validation cohort, with the NPV remaining above 99%. Taking into account the local reimbursement rates of diagnostic tests, using this strategy led to a 6.9% reduction of diagnostic costs for pulmonary embolism and a 5.1% reduction for deep vein thrombosis, as imaging tests would be avoided in a higher percentage of patients. CONCLUSION The diagnostic strategy of VTE based on the age-adjusted cut-off level for D-dimer in patients over 50 years was found to be safe, with NPV above 99%, and cost-effective.
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Affiliation(s)
- Neila De Pooter
- Hematology Laboratory, Emile Müller Regional Hospital, Mulhouse, France
- Hematology Laboratory, Grasse Hospital, Grasse, France
| | | | - Motalib Smahi
- Hematology Laboratory, Simone Veil Hospital, Eaubonne, France
| | - Lien Abecassis
- Hematology Laboratory, Jean Verdier Hospital, Aulnay-sous-Bois, France
| | - Pierre Toulon
- Hematology Department, Côte d'Azur University, Pasteur University Hospital, Nice, France
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6
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van Dam LF, Kroft LJM, Huisman MV, Ninaber MK, Klok FA. Computed Tomography Pulmonary Perfusion for Prediction of Short-Term Clinical Outcome in Acute Pulmonary Embolism. TH OPEN 2021; 5:e66-e72. [PMID: 33585787 PMCID: PMC7875679 DOI: 10.1055/s-0041-1723782] [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: 11/10/2020] [Accepted: 12/18/2020] [Indexed: 11/18/2022] Open
Abstract
Background
Computed tomography pulmonary angiography (CTPA) is the imaging modality of choice for the diagnosis of acute pulmonary embolism (PE). With computed tomography pulmonary perfusion (CTPP) additional information on lung perfusion can be assessed, but its value in PE risk stratification is unknown. We aimed to evaluate the correlation between CTPP-assessed perfusion defect score (PDS) and clinical presentation and its predictive value for adverse short-term outcome of acute PE.
Patients and Methods
This was an exploratory, observational study in 100 hemodynamically stable patients with CTPA-confirmed acute PE in whom CTPP was performed as part of routine clinical practice. We calculated the difference between the mean PDS in patients with versus without chest pain, dyspnea, and hemoptysis and 7-day adverse outcome. Multivariable logistic regression analysis and likelihood-ratio test were used to assess the added predictive value of PDS to CTPA parameters of right ventricle dysfunction and total thrombus load, for intensive care unit admission, reperfusion therapy and PE-related death.
Results
We found no correlation between PDS and clinical symptoms. PDS was correlated to reperfusion therapy (
n
= 4 with 16% higher PDS, 95% confidence interval [CI]: 3.5–28%) and PE-related mortality (
n
= 2 with 22% higher PDS, 95% CI: 4.9–38). Moreover, PDS had an added predictive value to CTPA assessment for PE-related mortality (from Chi-square 14 to 19,
p
= 0.02).
Conclusion
CTPP-assessed PDS was not correlated to clinical presentation of acute PE. However, PDS was correlated to reperfusion therapy and PE-related mortality and had an added predictive value to CTPA-reading for PE-related mortality; this added value needs to be demonstrated in larger studies.
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Affiliation(s)
- Lisette F van Dam
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Maarten K Ninaber
- Department of Pulmonology, 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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7
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Diagnostic accuracy of magnetic resonance imaging in patients with suspected pulmonary embolism: A bivariate meta-analysis. Thromb Res 2017; 154:64-72. [DOI: 10.1016/j.thromres.2017.03.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Revised: 03/18/2017] [Accepted: 03/31/2017] [Indexed: 01/26/2023]
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8
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Abstract
Deep vein thrombosis and pulmonary embolism, collectively referred to as venous thromboembolism, constitute a major global burden of disease. The diagnostic work-up of suspected deep vein thrombosis or pulmonary embolism includes the sequential application of a clinical decision rule and D-dimer testing. Imaging and anticoagulation can be safely withheld in patients who are unlikely to have venous thromboembolism and have a normal D-dimer. All other patients should undergo ultrasonography in case of suspected deep vein thrombosis and CT in case of suspected pulmonary embolism. Direct oral anticoagulants are first-line treatment options for venous thromboembolism because they are associated with a lower risk of bleeding than vitamin K antagonists and are easier to use. Use of thrombolysis should be limited to pulmonary embolism associated with haemodynamic instability. Anticoagulant treatment should be continued for at least 3 months to prevent early recurrences. When venous thromboembolism is unprovoked or secondary to persistent risk factors, extended treatment beyond this period should be considered when the risk of recurrence outweighs the risk of major bleeding.
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Affiliation(s)
- Marcello Di Nisio
- Department of Medical, Oral and Biotechnological Sciences, Gabriele D'Annunzio University, Chieti, Italy; Department of Vascular Medicine, Academic Medical Centre, Amsterdam, Netherlands.
| | - Nick van Es
- Department of Vascular Medicine, Academic Medical Centre, Amsterdam, Netherlands
| | - Harry R Büller
- Department of Vascular Medicine, Academic Medical Centre, Amsterdam, Netherlands
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D-Dimer and prothrombin fragment 1 + 2 in urine and plasma in patients with clinically suspected venous thromboembolism. Blood Coagul Fibrinolysis 2016; 27:396-400. [DOI: 10.1097/mbc.0000000000000461] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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10
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Systematic Comparison of Reduced Tube Current Protocols for High-pitch and Standard-pitch Pulmonary CT Angiography in a Large Single-center Population. Acad Radiol 2016; 23:619-27. [PMID: 26905455 DOI: 10.1016/j.acra.2016.01.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 12/15/2015] [Accepted: 01/10/2016] [Indexed: 11/23/2022]
Abstract
RATIONALE AND OBJECTIVES Benefits of iterative reconstruction (IR) algorithms combined with dose-reduction techniques have been shown at computed tomography pulmonary angiography (CTPA) in several medium to small patient collectives. In this study, we performed a systematic comparison of image quality to combinations of reduced tube current (RC) and IR for both standard-pitch (SP) single-source and high-pitch (HP) dual-source CTPA in a large, single-center population. MATERIALS AND METHODS Three hundred eighty-two consecutive patients (October 2010 through December 2012) received clinically indicated CTPA with one of four consecutively changed protocols: (1) HPSC: 180 mAs, weighted filtered back projection, pitch = 3; (2) HPRC: 90 mAs, IR, pitch = 3; (3) SPSC: 180 mAs, weighted filtered back projection, pitch = 1.2; and (4) HPRC: 90 mAs, IR, pitch = 1.2. Tube potential was 100 kV. Vascular attenuation and standardized signal-to-noise ratio (sSNR) were measured in the pulmonary trunk (sSNRPT) and on segmental artery level (sSNRS1, sSNRS10). Dose-length-product was recorded per series. Two independent investigators rated image quality. Kolmogorov-Smirnov test, Kruskal-Wallis test, and kappa statistics were used for statistical analysis. Median values are presented per group. RESULTS Image quality was consistent between all groups (observer 1: P = 0.118; observer 2: P = 0.122). Inter-reader consistency was very good (κ = 0.866, P < 0.001). Dose-length-product was significantly reduced in HP and RC groups (P < 0.001 for each; SPSC: 139.5 mGycm; HPRC: 92 mGycm; SPSC: 211 mGycm; HPRC: 137 mGycm). sSNR was comparable (sSNRPT overall: P = 0.052; sSNRS1 overall: P = 0.161; and sSNRS10 overall: P = 0.259). CONCLUSIONS Substantial dose reduction can be within a routine clinical setting without quantifiable loss of image quality either by HP pulmonary angiography or by a combination of IR and RC in either HP or SP acquisition.
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11
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Yang S, Yang Y, Zhai Z, Kuang T, Gong J, Zhang S, Zhu J, Liang L, Shen YH, Wang C. Incidence and risk factors of chronic thromboembolic pulmonary hypertension in patients after acute pulmonary embolism. J Thorac Dis 2015; 7:1927-38. [PMID: 26716031 DOI: 10.3978/j.issn.2072-1439.2015.11.43] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Early identification and treatment of chronic thromboembolic pulmonary hypertension (CTEPH) are critical to prevent disease progression. We determined the incidence and risk factors for CTEPH in patients with a first episode of acute pulmonary embolism (PE). METHODS In this study, consecutive patients with first-episode acute PE were followed for ≤5 years. Pulmonary hypertension (PH) was screened for by echocardiography. Suspected cases were evaluated by right heart catheterization (RHC) and pulmonary angiography (PA). If invasive procedures were not permitted, PH was diagnosed by systolic pulmonary artery pressure (SPAP) >50 mmHg. Diagnosis of CTEPH was confirmed by PA, ventilation/perfusion (V/Q) lung scan, or computed tomography (CT) PA (CTPA). RESULTS Overall, 614 patients with acute PE were included (median follow-up, 3.3 years). Ten patients were diagnosed with CTEPH: cumulative incidence 0.8% [95% confidence interval (CI), 0.0-1.6%] at 1 year, 1.3% (95% CI, 0.3-2.3%) at 2 years, and 1.7% (95% CI, 0.7-2.7%) at 3 years. No cases of CTEPH developed after 3 years. History of lower-limb varicose veins [hazard ratio (HR), 4.3; 95% CI, 1.2-15.4; P=0.024], SPAP >50 mmHg at initial PE episode (HR, 23.5; 95% CI, 2.7-207.6; P=0.005), intermediate-risk PE (HR, 1.2; 95% CI, 1.0-1.4; P=0.030), and CT obstruction index over 30% at 3 months after acute PE (HR, 42.5; 95% CI, 4.4-409.8; P=0.001) were associated with increased risk of CTEPH. CONCLUSIONS CTEPH was not rare after acute PE in this Chinese population, especially within 3 years of diagnosis. Lower-limb varicose veins, intermediate-risk PE with elevated SPAP in the acute phase, and residual emboli during follow-up might increase the risk of CTEPH.
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Affiliation(s)
- Suqiao Yang
- 1 Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China ; 2 Beijing Institute of Respiratory Medicine, Beijing 100020, China ; 3 Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing 100020, China ; 4 Center of Respiratory Medicine, Beijing Hospital, Ministry of Health, Beijing 100730, China ; 5 Department of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Texas, USA ; 6 Department of Respiratory Medicine, Capital Medical University, Beijing 100069, China ; 7 China-Japan Friendship Hospital, Beijing 100029, China
| | - Yuanhua Yang
- 1 Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China ; 2 Beijing Institute of Respiratory Medicine, Beijing 100020, China ; 3 Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing 100020, China ; 4 Center of Respiratory Medicine, Beijing Hospital, Ministry of Health, Beijing 100730, China ; 5 Department of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Texas, USA ; 6 Department of Respiratory Medicine, Capital Medical University, Beijing 100069, China ; 7 China-Japan Friendship Hospital, Beijing 100029, China
| | - Zhenguo Zhai
- 1 Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China ; 2 Beijing Institute of Respiratory Medicine, Beijing 100020, China ; 3 Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing 100020, China ; 4 Center of Respiratory Medicine, Beijing Hospital, Ministry of Health, Beijing 100730, China ; 5 Department of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Texas, USA ; 6 Department of Respiratory Medicine, Capital Medical University, Beijing 100069, China ; 7 China-Japan Friendship Hospital, Beijing 100029, China
| | - Tuguang Kuang
- 1 Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China ; 2 Beijing Institute of Respiratory Medicine, Beijing 100020, China ; 3 Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing 100020, China ; 4 Center of Respiratory Medicine, Beijing Hospital, Ministry of Health, Beijing 100730, China ; 5 Department of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Texas, USA ; 6 Department of Respiratory Medicine, Capital Medical University, Beijing 100069, China ; 7 China-Japan Friendship Hospital, Beijing 100029, China
| | - Juanni Gong
- 1 Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China ; 2 Beijing Institute of Respiratory Medicine, Beijing 100020, China ; 3 Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing 100020, China ; 4 Center of Respiratory Medicine, Beijing Hospital, Ministry of Health, Beijing 100730, China ; 5 Department of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Texas, USA ; 6 Department of Respiratory Medicine, Capital Medical University, Beijing 100069, China ; 7 China-Japan Friendship Hospital, Beijing 100029, China
| | - Shuai Zhang
- 1 Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China ; 2 Beijing Institute of Respiratory Medicine, Beijing 100020, China ; 3 Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing 100020, China ; 4 Center of Respiratory Medicine, Beijing Hospital, Ministry of Health, Beijing 100730, China ; 5 Department of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Texas, USA ; 6 Department of Respiratory Medicine, Capital Medical University, Beijing 100069, China ; 7 China-Japan Friendship Hospital, Beijing 100029, China
| | - Jianguo Zhu
- 1 Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China ; 2 Beijing Institute of Respiratory Medicine, Beijing 100020, China ; 3 Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing 100020, China ; 4 Center of Respiratory Medicine, Beijing Hospital, Ministry of Health, Beijing 100730, China ; 5 Department of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Texas, USA ; 6 Department of Respiratory Medicine, Capital Medical University, Beijing 100069, China ; 7 China-Japan Friendship Hospital, Beijing 100029, China
| | - Lirong Liang
- 1 Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China ; 2 Beijing Institute of Respiratory Medicine, Beijing 100020, China ; 3 Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing 100020, China ; 4 Center of Respiratory Medicine, Beijing Hospital, Ministry of Health, Beijing 100730, China ; 5 Department of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Texas, USA ; 6 Department of Respiratory Medicine, Capital Medical University, Beijing 100069, China ; 7 China-Japan Friendship Hospital, Beijing 100029, China
| | - Ying H Shen
- 1 Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China ; 2 Beijing Institute of Respiratory Medicine, Beijing 100020, China ; 3 Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing 100020, China ; 4 Center of Respiratory Medicine, Beijing Hospital, Ministry of Health, Beijing 100730, China ; 5 Department of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Texas, USA ; 6 Department of Respiratory Medicine, Capital Medical University, Beijing 100069, China ; 7 China-Japan Friendship Hospital, Beijing 100029, China
| | - Chen Wang
- 1 Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China ; 2 Beijing Institute of Respiratory Medicine, Beijing 100020, China ; 3 Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing 100020, China ; 4 Center of Respiratory Medicine, Beijing Hospital, Ministry of Health, Beijing 100730, China ; 5 Department of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Texas, USA ; 6 Department of Respiratory Medicine, Capital Medical University, Beijing 100069, China ; 7 China-Japan Friendship Hospital, Beijing 100029, China
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12
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Zhou M, Hu Y, Long X, Liu D, Liu L, Dong C, Wang J, Kong X. Diagnostic performance of magnetic resonance imaging for acute pulmonary embolism: a systematic review and meta-analysis. J Thromb Haemost 2015; 13:1623-34. [PMID: 26179627 DOI: 10.1111/jth.13054] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 07/07/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND With ongoing technical developments, magnetic resonance imaging (MRI) has notably evolved for the assessment of the pulmonary vasculature. However, uncertainty persists about the performance of MRI for the diagnosis of acute pulmonary embolism (APE). OBJECTIVES To clarify the comprehensive role of MRI in diagnosing APE. METHODS Studies were identified through a search of Pubmed and Ovid databases, and the QUADAS-2 tool was applied for quality assessment of the included studies. RESULTS Fifteen studies based on patients and nine based on vessels were retrieved. The patient-based analysis yielded an overall sensitivity of 0.75 (95% confidence interval, 0.70-0.79) and 0.84 (0.80-0.87) for all patients and patients with technically adequate images, respectively, with an overall specificity of 0.80 (0.77-0.83) and 0.97 (0.96-0.98) and a pooled diagnostic odds ratio (DOR) of 51.07 (18.36-142.05) and 155.22 (86.83-277.47). On average, MRI was technically inadequate in 18.89% of patients (range, 2.10%-27.70%). A direct comparison of different MRI modalities showed that the combined MRI test had the highest pooled DOR and the lowest proportion of inconclusive images. Of note, heterogeneity and moderate quality were observed. On a vessel basis, the MRI had high sensitivity and specificity in larger-order vessels, but a significantly lower sensitivity of 0.55 (0.50-0.60) for subsegmental APE. CONCLUSIONS On a patient-based level, MRI yields high diagnostic accuracy for the detection of APE, especially in technically adequate images, and the inconclusive MRI examinations mainly result from motion artifact and poor arterial opacification. The combined MRI test appears to be a more promising diagnostic tool with greater power of discrimination than single techniques. From a vessel-based perspective, MRI exhibits a high diagnostic capability with proximal arteries, but lacks sensitivity for peripheral embolism.
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Affiliation(s)
- M Zhou
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Y Hu
- Tumor Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - X Long
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - D Liu
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - L Liu
- Tumor Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - C Dong
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - J Wang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - X Kong
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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Squizzato A, Galli L, Gerdes VEA. Point-of-care ultrasound in the diagnosis of pulmonary embolism. Crit Ultrasound J 2015; 7:7. [PMID: 26034556 PMCID: PMC4447771 DOI: 10.1186/s13089-015-0025-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 05/14/2015] [Indexed: 01/02/2023] Open
Abstract
The best diagnostic strategy to confirm or exclude pulmonary embolism (PE) suspicion needs an appropriate combination of clinical assessment, plasma D-dimer measurement, and computed tomographic pulmonary angiography (CTPA). CTPA should be used with caution in some patient groups, such as patients with known allergy to contrast media, those with severe renal insufficiency, and pregnant women, and could be not immediately available in case of unstable patients. In the emergency setting, alternative diagnostic strategies should be implemented to overcome CTPA limitations. Ultrasonography is certainly a valuable alternative diagnostic tool. In addition to echocardiography and lower limb compressive venous ultrasonography, lung ultrasound (US) may play an important role in selected patients’ subgroups. Recent data on the diagnostic performance of a triple point-of-care US (lung, heart, and leg vein US) are discussed in the present paper, and pros and cons of triple point-of-care US are compared with those of standard diagnostic approaches.
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Affiliation(s)
- Alessandro Squizzato
- Research Center on Thromboembolic Disorders and Antithrombotic Therapies, Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy ; U.O. Medicina I, Ospedale di Circolo, Viale Borri 57, 21100 Varese, Italy
| | - Luca Galli
- Research Center on Thromboembolic Disorders and Antithrombotic Therapies, Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy ; Department of Medicine, Slotervaart Hospital, Amsterdam, The Netherlands ; Department of Vascular Medicine, Academic Medical Centre, Amsterdam, The Netherlands
| | - Victor E A Gerdes
- Department of Medicine, Slotervaart Hospital, Amsterdam, The Netherlands ; Department of Vascular Medicine, Academic Medical Centre, Amsterdam, The Netherlands
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14
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Sivananthan G, Halin NJ, Estes JM, Alessi-Chinetti JM, Polak JF. Value of complete full-length lower extremity sonography in patients undergoing computed tomographic pulmonary angiography. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2014; 33:2137-2143. [PMID: 25425370 DOI: 10.7863/ultra.33.12.2137] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVES To evaluate the diagnostic yield of complete lower extremity venous sonography for diagnosing deep venous thrombosis (DVT) in patients undergoing computed tomographic (CT) pulmonary angiography for suspected pulmonary embolism (PE). METHODS We retrospectively reviewed all cases of lower extremity venous sonography and CT pulmonary angiography performed within 1 day of each other (n = 147) in a tertiary care center. Indications for the studies performed, angiographic findings, sonographic findings, age, sex, inpatient/outpatient status, lower extremity symptoms, and treatment status were recorded. Prevalence rates and patient characteristics were compared by χ(2) and Fisher exact probability tests where appropriate. Multivariable logistic regression with acute PE as the outcome was performed for age, sex, interval between angiography and sonography, indication for angiography, inpatient/outpatient status, and venous sonographic findings. RESULTS The prevalence of PE (23.8%) was similar to the prevalence of DVT (27.9%). Angiographic findings were not associated with the interval between angiography and sonography or inpatient/outpatient status. Acute DVT was more likely (P = .0009) when angiographic findings were positive (51.4%), but DVT prevalence was still substantial (20.5%) in patients with negative angiographic findings. Lower extremity symptoms were not associated with DVT in cases with negative angiographic findings (P = .48). Eighteen of the 23 patients with acute DVT and negative angiographic findings were treated. CONCLUSIONS There is a high rate of DVT in a population undergoing CT pulmonary angiography for suspected PE even when PE is not diagnosed. Our data apply to a tertiary care institution, suggest a surveillance bias, and favor the utility of venous sonography in this population.
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Affiliation(s)
- Gajan Sivananthan
- Departments of Radiology (G.S., N.J.H., J.F.P.) and Vascular Surgery (J.M.E., J.M.A.-C.), Tufts Medical Center, Boston, Massachusetts USA.
| | - Neil J Halin
- Departments of Radiology (G.S., N.J.H., J.F.P.) and Vascular Surgery (J.M.E., J.M.A.-C.), Tufts Medical Center, Boston, Massachusetts USA
| | - James M Estes
- Departments of Radiology (G.S., N.J.H., J.F.P.) and Vascular Surgery (J.M.E., J.M.A.-C.), Tufts Medical Center, Boston, Massachusetts USA
| | - Jean M Alessi-Chinetti
- Departments of Radiology (G.S., N.J.H., J.F.P.) and Vascular Surgery (J.M.E., J.M.A.-C.), Tufts Medical Center, Boston, Massachusetts USA
| | - Joseph F Polak
- Departments of Radiology (G.S., N.J.H., J.F.P.) and Vascular Surgery (J.M.E., J.M.A.-C.), Tufts Medical Center, Boston, Massachusetts USA
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15
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Bujak R, García-Álvarez A, Rupérez FJ, Nuño-Ayala M, García A, Ruiz-Cabello J, Fuster V, Ibáñez B, Barbas C. Metabolomics reveals metabolite changes in acute pulmonary embolism. J Proteome Res 2014; 13:805-16. [PMID: 24367941 DOI: 10.1021/pr400872j] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Pulmonary embolism (PE) is a common cardiovascular emergency which can lead to pulmonary hypertension (PH) and right ventricular failure as a consequence of pulmonary arterial bed occlusion. The diagnosis of PE is challenging due to nonspecific clinical presentation, which results in relatively high mortality. Moreover, the pathological factors associated with PE are poorly understood. Metabolomics can provide new highlights which can help in the understanding of the processes and even propose biomarkers for its diagnosis. In order to obtain more information about PE and PH, acute PE was induced in large white pigs and plasma was obtained before and after induction of PE. Metabolic fingerprints from plasma were obtained with LC-QTOF-MS (positive and negative ionization) and GC-Q-MS. Data pretreatment and statistical analysis (uni- and multivariate) were performed in order to compare metabolic fingerprints and to select the metabolites that showed higher loading for the classification (28 from LC and 19 from GC). The metabolites found differentially distributed among groups are mainly related to energy imbalance in hypoxic conditions, such as glycolysis-derived metabolites, ketone bodies, and TCA cycle intermediates, as well as a group of lipidic mediators that could be involved in the transduction of the signals to the cells such as sphingolipids and lysophospholipids, among others. Results presented in this report reveal that combination of LC-MS- and GC-MS-based metabolomics could be a powerful tool for diagnosis and understanding pathophysiological processes due to acute PE.
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Affiliation(s)
- Renata Bujak
- Centre for Metabolomics and Bioanalysis (CEMBIO), Facultad de Farmacia, Universidad CEU San Pablo , Campus Monteprincipe, Boadilla del Monte 28668, Madrid, Spain
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16
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den Exter PL, van Es J, Erkens PMG, van Roosmalen MJG, van den Hoven P, Hovens MMC, Kamphuisen PW, Klok FA, Huisman MV. Impact of delay in clinical presentation on the diagnostic management and prognosis of patients with suspected pulmonary embolism. Am J Respir Crit Care Med 2013; 187:1369-73. [PMID: 23590273 DOI: 10.1164/rccm.201212-2219oc] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
RATIONALE The nonspecific clinical presentation of pulmonary embolism (PE) frequently leads to delay in its diagnosis. OBJECTIVES This study aimed to assess the impact of delay in presentation on the diagnostic management and clinical outcome of patients with suspected PE. METHODS In 4,044 consecutive patients with suspected PE, patients presenting more than 7 days from the onset of symptoms were contrasted with those presenting within 7 days as regards the safety of excluding PE on the basis of a clinical decision rule combined with D-dimer testing. Patients were followed for 3 months to assess the rates of recurrent venous thromboembolism and mortality. MEASUREMENTS AND MAIN RESULTS A delayed presentation (presentation >7 d) was present in 754 (18.6%) of the patients. The failure rate of an unlikely clinical probability and normal D-dimer test was 0.5% (95% confidence interval [CI], 0.01-2.7) for patients with and 0.5% (95% CI, 0.2-1.2) for those without diagnostic delay. D-dimer testing yielded a sensitivity of 99% (95% CI, 96-99%) and 98% (95% CI, 97-99%) in these groups, respectively. Patients with PE with diagnostic delay more frequently had centrally located PE (41% vs. 26%; P < 0.001). The cumulative rates of recurrent venous thromboembolism (4.6% vs. 2.7%; P = 0.14) and mortality (7.6% vs. 6.6%; P = 0.31) were not different for patients with and without delayed presentation. CONCLUSIONS PE can be safely excluded based on a clinical decision rule and D-dimer testing in patients with a delayed clinical presentation. A delayed presentation for patients who survived acute PE was associated with a more central PE location, although this did not affect the clinical outcome at 3 months.
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Affiliation(s)
- Paul L den Exter
- Department of Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, The Netherlands.
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17
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Squizzato A, Rancan E, Dentali F, Bonzini M, Guasti L, Steidl L, Mathis G, Ageno W. Diagnostic accuracy of lung ultrasound for pulmonary embolism: a systematic review and meta-analysis. J Thromb Haemost 2013; 11:1269-78. [PMID: 23574640 DOI: 10.1111/jth.12232] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Accepted: 04/03/2013] [Indexed: 08/31/2023]
Abstract
BACKGROUND Computed tomographic pulmonary angiography (CTPA) has simplified the diagnostic approach to patients with suspected pulmonary embolism (PE). However, PE diagnosis is still probabilistic and CTPA should be used with caution in some patient groups, such as patients with severe renal insufficiency and pregnant women. Among alternative imaging tests, lung ultrasound is the most promising technique. We aimed to systematically assess the diagnostic accuracy of lung ultrasound for PE diagnosis. METHODS Studies evaluating the diagnostic accuracy of lung ultrasound for the diagnosis of PE were systematically searched for in the MEDLINE and EMBASE databases (up to June 2012). The QUADAS-2 tool was used for the quality assessment of the primary studies. A bivariate random-effects regression approach was used for summary estimates of both sensitivity and specificity. RESULTS Ten studies, for a total of 887 patients, were included. A composite reference test was used in six studies, with single-row detector CTPA as the principal imaging test in four studies. Overall, seven studies used a proper reference test. Lung ultrasound bivariate weighted mean sensitivity was 87.0% (95% confidence interval [CI] 79.5, 92.0%), whereas bivariate weighted mean specificity was 81.8% (95% CI 71.0, 89.3%). CONCLUSIONS Our findings suggest that lung ultrasound may be a useful diagnostic tool in the management of patients with suspected PE. However, several methodological drawbacks of the primary studies limit any definite conclusion. Further well-designed accuracy studies are necessary before planning diagnostic management studies, in particular in those with a contraindication for CTPA.
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Affiliation(s)
- A Squizzato
- Research Center on Thromboembolic Disorders and Antithrombotic Therapies, Department of Clinical and Experimental Medicine, University of Insubria, Viale Borri 57,Varese, Italy.
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18
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Huisman MV, Klok FA. Diagnostic management of acute deep vein thrombosis and pulmonary embolism. J Thromb Haemost 2013; 11:412-22. [PMID: 23294863 DOI: 10.1111/jth.12124] [Citation(s) in RCA: 117] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Acute deep vein thrombosis (DVT) and pulmonary embolism (PE) represent two expressions of a similar clinical pathological process, often referred to as venous thromboembolism (VTE). It has long been recognized that, as clinical signs and symptoms of PE and DVT are not specific for the diagnosis, objective diagnosis in both patients presenting with leg symptoms and those with chest symptoms is mandatory. Since the last review on this subject in this journal in 2009, several large trials have been performed that shed new light on all aspects of the diagnostic management of suspected VTE, especially in the field of simplified clinical decision rules, age-dependent D-dimer cut-offs and magnetic resonance imaging. A literature search covering the period 2007-2012 was performed using the Medline/PubMed database to identify all relevant papers regarding the diagnostic management of acute PE and DVT. Established concepts and the latest evidence on this subject will be the main focus of this review.
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Affiliation(s)
- M V Huisman
- Department of Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, the Netherlands.
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19
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Comparison of Pulmonary Embolism and Subsequent Cardiovascular Events Between Elderly and Young Patients in the Emergency Department. INT J GERONTOL 2012. [DOI: 10.1016/j.ijge.2012.01.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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20
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Huisman MV, Klok FA. Magnetic resonance imaging for diagnosis of acute pulmonary embolism: not yet a suitable alternative to CT-PA. J Thromb Haemost 2012; 10:741-2. [PMID: 22375614 DOI: 10.1111/j.1538-7836.2012.04678.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- M V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
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Forsythe RM, Peitzman AB, DeCato T, Rosengart MR, Watson GA, Marshall GT, Ziembicki JA, Billiar TR, Sperry JL. Early lower extremity fracture fixation and the risk of early pulmonary embolus: filter before fixation? ACTA ACUST UNITED AC 2011; 70:1381-8. [PMID: 21817975 DOI: 10.1097/ta.0b013e318215b928] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Venous thromboembolism is a major cause of morbidity and mortality after injury. Prophylactic anticoagulation is often delayed as a result of injuries or required procedures. Those patients at highest risk in this early vulnerable window postinjury are not well characterized. We sought to determine those patients at highest risk for an early pulmonary embolism (PE) after injury. METHODS A retrospective analysis using data derived from a large state wide trauma registry (1997-2007) was performed. Patients with a documented PE and time of occurrence were selected (n = 712). Patients with fat emboli and lower extremity vascular injuries were excluded. Patients with a PE within the first 72 hours of admission (EARLY, n = 122) were compared with those with DELAYED presentation. Kaplan-Meier survival analysis was used to characterize the timing of death between the two groups. Backward stepwise logistic regression was used to determine independent risk factors for EARLY PE relative to those with DELAYED PE. RESULTS EARLY and DELAYED groups were similar in age, gender, Glasgow Coma Scale, emergency department systolic blood pressure, and injury mechanism. The EARLY PE group had a lower Injury Severity Score but injuries more commonly included femur fracture. Kaplan-Meier analysis revealed that EARLY PE patients have a significantly higher risk of early mortality relative to DELAYED PE patients (p = 0.012). Regression analysis revealed that the only independent risk factor for EARLY PE was lower extremity/pelvic orthopedic fixation (<48 hours from injury). The risk of EARLY PE was more than threefold higher (odds ratios, 3.85; 95% CI, 1.9-7.6; p < 0.001) for those who underwent early lower extremity orthopedic fixation versus those who did not. CONCLUSION Early lower extremity/pelvis orthopedic fixation is the single independent predictor of EARLY PE in this patient cohort. Venous thromboembolism/PE prevention strategies should be made a priority in this group of patients, including early preoperative institution of anticoagulation prophylaxis. These results suggest that those with contraindications to early anticoagulation may benefit from insertion of retrievable inferior vena cava filters preoperatively.
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Affiliation(s)
- Raquel M Forsythe
- Division of General Surgery and Trauma, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213, USA.
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van der Bijl N, Klok FA, Huisman MV, van Rooden JK, Mertens BJ, de Roos A, Kroft LJ. Measurement of Right and Left Ventricular Function by ECG-Synchronized CT Scanning in Patients With Acute Pulmonary Embolism. Chest 2011; 140:1008-1015. [DOI: 10.1378/chest.10-3174] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Klok FA, Romeih S, Kroft LJM, Westenberg JJM, Huisman MV, de Roos A. Recovery of right and left ventricular function after acute pulmonary embolism. Clin Radiol 2011; 66:1203-7. [PMID: 21899831 DOI: 10.1016/j.crad.2011.08.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2011] [Revised: 07/29/2011] [Accepted: 08/01/2011] [Indexed: 11/16/2022]
Abstract
AIM To evaluate recovery of cardiac function after acute pulmonary embolism (PE). MATERIALS AND METHODS Routine breath-held computed tomography (CT)-pulmonary angiography was performed in patients with suspected PE to confirm or exclude the diagnosis of PE at initial presentation. Electrocardiogram (ECG)-triggered cardiac CT was performed to assess biventricular function. After 6 months, cardiac magnetic resonance imaging (MRI) was performed. In total, 15 consecutive patients with PE and 10 without were studied. A significant change in ventricular volume was defined as a >15% change in end-diastolic or -systolic volumes (EDV, ESV), and significant ventricular function improvement as a >5% increase in ejection fraction (EF) as based on reported cut-off values. RESULTS Right and left ventricular (RV and LV) EDV and ESV changed non-significantly (<1.3%) in the patients without PE, indicating good comparability of those values measured by CT and MRI. PE patients with baseline normal RV function (RVEF ≥ 47%) revealed a >5% improvement in the RVEF (+5.4 ± 3.1%) due to a decrease in the RVESV. Patients with baseline abnormal RV function showed a >5% improvement in the RVEF (+14 ± 15%) due to decreases in both the RVESV and RVEDV. Furthermore, the LVEDV increased in this latter patient group. CONCLUSIONS The present study demonstrated an improvement in RV function in the majority of patients with PE, independent of baseline RV function. The degree of RV and LV recovery was dependent on the severity of baseline RV dysfunction.
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Affiliation(s)
- F A Klok
- Section of Vascular Medicine, Department of General Internal Medicine-Endocrinology, Leiden University Medical Center, Leiden, The Netherlands.
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Computed tomography pulmonary angiography as a single imaging test to rule out pulmonary embolism. Curr Opin Pulm Med 2011; 17:380-6. [DOI: 10.1097/mcp.0b013e328348b3de] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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25
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Klok F, Surie S, Kempf T, Eikenboom J, van Straalen J, van Kralingen K, van Dijk A, Vliegen H, Bresser P, Wollert K, Huisman M. A simple non-invasive diagnostic algorithm for ruling out chronic thromboembolic pulmonary hypertension in patients after acute pulmonary embolism. Thromb Res 2011; 128:21-6. [DOI: 10.1016/j.thromres.2011.03.004] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2011] [Revised: 02/20/2011] [Accepted: 03/06/2011] [Indexed: 10/18/2022]
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Klok FA, Romeih S, Westenberg JJM, Kroft LJM, Huisman MV, de Roos A. Pulmonary flow profile and distensibility following acute pulmonary embolism. J Cardiovasc Magn Reson 2011; 13:14. [PMID: 21332981 PMCID: PMC3055838 DOI: 10.1186/1532-429x-13-14] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2010] [Accepted: 02/18/2011] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE Proof of concept study evaluating CMR as screening tool for chronic thromboembolic pulmonary hypertension (CTEPH) in patients treated for acute pulmonary embolism (PE). MATERIALS AND METHODS Right and left ventricular function of 15 consecutive patients treated for PE and 10 consecutive patients in whom PE was excluded was estimated at baseline by cardiac CT and at 6 months follow-up by CMR. Additionally, during the follow-up visit, pulmonary artery (PA) hemodynamics were studied by CMR and the presence of pulmonary hypertension by echocardiography. RESULTS CT measured right ventricular ejection fraction (RVEF) was lower in patients with PE compared to patients without PE at time of diagnosis (median 47%, interquartile range 39-53 vs. 55%, 52-58; p = 0.014). After 6 months follow up, the RVEF between patients treated for PE and patients without PE were not statistically significant different (55%, 52-60 versus 54%, 51-57; p = 0.57), as were distensibility index (0.18 ± 0.18 versus 0.25 ± 0.18, p = 0.20), mean velocity (14.1 ± 3.9 cm/s versus 14.0 ± 2.5 cm/s, p = 0.81), peak velocity (86.5 ± 22 cm/s versus 89.6 ± 13 cm/s, p = 0.43) and time to peak PA blood flow velocity (142 ± 49 ms versus 161 ± 29 ms, p = 0.14). One patient was diagnosed with CTEPH and CMR revealed poor right systolic function, decreased PA distensibility and flow velocity, and a systolic notch in the PA flow profile consistent with persistent PA obstruction. CONCLUSION In this small series, right ventricular performance and PA flow profiles of patients treated for 6 months after PE are equivalent to those parameters in normal patients.
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Affiliation(s)
- Frederikus A Klok
- Section of Vascular medicine, department of General Internal Medicine-Endocrinology, LUMC, Leiden, the Netherlands
| | - Soha Romeih
- Department of Radiology, LUMC, Leiden, the Netherlands
| | | | | | - Menno V Huisman
- Section of Vascular medicine, department of General Internal Medicine-Endocrinology, LUMC, Leiden, the Netherlands
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Aviram G, Steinvil A, Berliner S, Rosen G, Sosna J, Man A, Keren G, Rogowski O. The association between the embolic load and atrial size in acute pulmonary embolism. J Thromb Haemost 2011; 9:293-9. [PMID: 21040447 DOI: 10.1111/j.1538-7836.2010.04130.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Early identification by computed tomography pulmonary angiography (CTPA) of patients with acute pulmonary embolism (PE) who have signs associated with a high embolic burden would be highly desirable. OBJECTIVES To investigate whether an increased obstruction of the pulmonary vasculature is associated with reduced left atrial (LA) and increased right atrial (RA) areas. METHODS We retrospectively analyzed a consecutive series of CTPA studies of 137 patients with acute PE and 38 controls without PE between October 2004 and March 2006. Left and right atrial areas and longitudinal and short axis diameters were measured and correlated with the pulmonary arterial obstruction index (PAOI) divided into tertiles (obstruction of < 12.5%, 12.5%-42.5% and ≥ 42.5%). RESULTS There was a significant negative age- and gender-adjusted correlation between the PAOI and LA measurements, particularly the LA area (r = -0.259) and the LA short axis diameter (r = -0.331). All RA measurements had positive correlations (RA area, r = 0.279; RA short axis diameter, r = 0.313). The LA/RA area ratio correlated negatively with the PAOI (r = -0.447). All above-mentioned correlations had P < 0.002. All the LA measurements were the largest in the controls and gradually decreased with higher PAOIs. A receiver operating characteristic curve analysis demonstrated that the RV/LV diameter, LA/RA area and LA/RA short axis diameter ratios had comparable discriminative ability for higher PAOI tertiles. CONCLUSIONS The higher the clot load in the pulmonary arteries, the smaller the LA area and the larger the RA area. Atrial area measurements by CTPA may serve as a real-time parameter in assessing the severity of PE upon diagnosis.
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Affiliation(s)
- G Aviram
- Department of Radiology, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Cereser L, Bagatto D, Girometti R, Como G, Zuiani C, Bazzocchi M. Chest multidetector computed tomography (MDCT) in patients with suspected acute pulmonary embolism: diagnostic yield and proportion of other clinically relevant findings. LA RADIOLOGIA MEDICA 2010; 116:219-29. [PMID: 21311990 DOI: 10.1007/s11547-010-0612-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2010] [Accepted: 05/11/2010] [Indexed: 11/25/2022]
Abstract
PURPOSE The authors evaluated the diagnostic yield of chest multidetector computed tomography (MDCT) in acute pulmonary embolism (PE) and the proportion of other clinically relevant findings in a large cohort of consecutive inpatients and patients referred from the emergency department (outpatients). MATERIALS AND METHODS A total of 327 radiological reports of chest MDCT scans performed for suspected acute PE in 327 patients (158 men, 169 women; mean age 69 years, standard deviation 17.33 years; 233 inpatients, 94 outpatients) were retrospectively evaluated and classified into four categories: 1, positive for PE; 2, negative for PE but positive for other findings requiring specific and immediate intervention; 3, completely negative or positive for findings with a potential for significant morbidity requiring specific action on follow-up; 4, indeterminate. The distribution of findings by categories among the entire population and inpatients and outpatients separately was calculated (chi-square test, α=0.05). RESULTS In the entire population, the diagnostic yield (i.e. proportion of cases classified as category 1) was 20.2% (66/327). Proportions of cases classified as categories 2, 3 and 4 were 27.5% (90/327), 44.3% (145/327) and 7.9% (26/327), respectively. No statistically significant difference was found between inpatients and outpatients (p=0.193). CONCLUSIONS In patients with suspected acute PE, chest MDCT provides evidence of conditions requiring immediate and specific intervention (i.e. categories 1 and 2) in nearly 50% of cases, without differences between inpatients and outpatients.
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Affiliation(s)
- L Cereser
- Institute of Diagnostic Radiology, University of Udine, Via Colugna 50, 33100, Udine, Italy.
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Fens N, Douma RA, Sterk PJ, Kamphuisen PW. Breathomics as a diagnostic tool for pulmonary embolism. J Thromb Haemost 2010; 8:2831-3. [PMID: 20860678 DOI: 10.1111/j.1538-7836.2010.04064.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
This article discusses pneumothorax, pneumomediastinum, and pulmonary embolism in pediatric practice. Although children appear to have better outcomes than adults, the risk factors are substantial. Topics covered include the pathophysiology incidence, presentation, diagnosis, and management of these diseases.
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Affiliation(s)
- Nakia N Johnson
- Section of Emergency Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin, Suite A-210, Houston, TX 77030, USA
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Klok F, van Kralingen K, van Dijk A, Heyning F, Vliegen H, Huisman M. Prevalence and potential determinants of exertional dyspnea after acute pulmonary embolism. Respir Med 2010; 104:1744-9. [DOI: 10.1016/j.rmed.2010.06.006] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2010] [Revised: 05/30/2010] [Accepted: 06/08/2010] [Indexed: 10/19/2022]
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Assessment of the alveolar-arterial oxygen gradient as a screening test for pulmonary embolism in pregnancy. Am J Obstet Gynecol 2010; 203:373.e1-4. [PMID: 20554265 DOI: 10.1016/j.ajog.2010.04.049] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2010] [Revised: 03/29/2010] [Accepted: 04/29/2010] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The objective of the study was to determine whether the alveolar-arterial (A-a) oxygen gradient is an adequate screening test for pulmonary embolism (PE) in pregnancy and postpartum. STUDY DESIGN A chart review was performed at Tampa General Hospital. Patients who had a workup for a PE consisting of a computed tomography pulmonary angiogram and an arterial blood gas from 2002 to 2009 were included in the analysis. Sensitivity, specificity, and negative and positive predictive values were calculated. Additionally, common clinical signs and symptoms were assessed for their ability to accurately predict PE. RESULTS Of 102 patients, there were 13 PEs (2 antepartum and 11 postpartum). The best sensitivity, specificity, and negative and positive predictive values for A-a gradients were 76.9%, 20.2%, 80.0%, and 11.5%, respectively. CONCLUSION The A-a gradient is a poor screening test for PE in pregnancy and postpartum. Suspicion of PE should prompt early imaging studies to rapidly make the diagnosis and begin treatment.
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Klok FA, van Kralingen KW, van Dijk APJ, Heyning FH, Vliegen HW, Kaptein AA, Huisman MV. Quality of life in long-term survivors of acute pulmonary embolism. Chest 2010; 138:1432-40. [PMID: 20495104 DOI: 10.1378/chest.09-2482] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND To our knowledge, studies evaluating the quality of life (QoL) in patients with a history of acute pulmonary embolism (PE) are not available, even though QoL is a key outcome component of medical care and a predictor of disease-specific prognosis. METHODS As part of a large follow-up study, the Short Form 36 (SF-36) was presented to consecutive patients who had survived one or more episodes of acute PE. The results of all nine subscales of the SF-36 were compared with sex- and age-adjusted Dutch population norms. Single and multivariate analyses were performed to identify independent determinants of the QoL in our study population. RESULTS The SF-36 was completed by 392 patients. Except for the health change subscale, patients had substantially lower QoL than population norms on all eight remaining subscales. After multivariate analysis, the time interval between the last thromboembolic episode and study inclusion was inversely related to QoL, and significant determinants of poor QoL were prior PE, age, obesity, active malignancy, and cardiopulmonary comorbid conditions. Regression models that included all identified significant determinants proved to be quite modest predictors for QoL in the individual patient. Awareness of illness, coping mechanisms, and self-management behavior might be additional important indicators of QoL in our study population but require further investigation. CONCLUSION We identified several PE- and non-PE-related determinants of QoL in patients with a history of acute PE, which is impaired compared with sex- and age-adjusted population norms. QoL after acute PE should be studied more extensively and added as a standard measure to outcome studies.
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Klok FA, van der Bijl N, de Roos A, Kroft LJM, Huisman MV. Is pulmonary embolism associated with reactive mediastinal and hilar lymphadenopathy? Thromb Res 2010; 125:557-8. [PMID: 20430420 DOI: 10.1016/j.thromres.2010.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2010] [Revised: 04/05/2010] [Accepted: 04/06/2010] [Indexed: 10/19/2022]
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Klok FA, Van Der Bijl N, Eikenboom HCJ, Van Rooden CJ, De Roos A, Kroft LJM, Huisman MV. Comparison of CT assessed right ventricular size and cardiac biomarkers for predicting short-term clinical outcome in normotensive patients suspected of having acute pulmonary embolism. J Thromb Haemost 2010; 8:853-6. [PMID: 20096002 DOI: 10.1111/j.1538-7836.2010.03780.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
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Klok FA, Zondag W, van Kralingen KW, van Dijk APJ, Tamsma JT, Heyning FH, Vliegen HW, Huisman MV. Patient Outcomes after Acute Pulmonary Embolism. Am J Respir Crit Care Med 2010; 181:501-6. [DOI: 10.1164/rccm.200907-1141oc] [Citation(s) in RCA: 113] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
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Kooiman J, Klok FA, Mos ICM, van der Molen A, de Roos A, Sijpkens YWJ, Huisman MV. Incidence and predictors of contrast-induced nephropathy following CT-angiography for clinically suspected acute pulmonary embolism. J Thromb Haemost 2010; 8:409-11. [PMID: 19943871 DOI: 10.1111/j.1538-7836.2009.03698.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Klok FA, van Kralingen KW, van Dijk APJ, Heyning FH, Vliegen HW, Huisman MV. Prospective cardiopulmonary screening program to detect chronic thromboembolic pulmonary hypertension in patients after acute pulmonary embolism. Haematologica 2010; 95:970-5. [PMID: 20053871 DOI: 10.3324/haematol.2009.018960] [Citation(s) in RCA: 170] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Chronic thromboembolic pulmonary hypertension after pulmonary embolism is associated with high morbidity and mortality. Understanding the incidence of chronic thromboembolic pulmonary hypertension after pulmonary embolism is important for evaluating the need for screening but is also a subject of debate because of different inclusion criteria among previous studies. We determined the incidence of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism and the utility of a screening program for this disease. DESIGN AND METHODS We conducted a cohort screening study in an unselected series of consecutive patients (n=866) diagnosed with acute pulmonary embolism between January 2001 and July 2007. All patients who had not been previously diagnosed with pulmonary hypertension (PH) and had survived until study inclusion were invited for echocardiography. Patients with echocardiographic suspicion of PH underwent complete work-up for chronic thromboembolic pulmonary hypertension, including ventilation-perfusion scintigraphy and right heart catheterization. RESULTS After an average follow-up of 34 months of all 866 patients, PH was diagnosed in 19 patients by routine clinical care and in 10 by our screening program; 4 patients had chronic thromboembolic pulmonary hypertension, all diagnosed by routine clinical care. The cumulative incidence of chronic thromboembolic pulmonary hypertension after all cause pulmonary embolism was 0.57% (95% confidence interval [CI] 0.02-1.2%) and after unprovoked pulmonary embolism 1.5% (95% CI 0.08-3.1%). CONCLUSIONS Because of the low incidence of chronic thromboembolic pulmonary hypertension after pulmonary embolism and the very low yield of the echocardiography based screening program, wide scale implementation of prolonged follow-up including echocardiography of all patients with pulmonary embolism to detect chronic thromboembolic pulmonary hypertension does not seem to be warranted.
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Affiliation(s)
- Frederikus A Klok
- Section of Vascular Medicine, Department of General Internal Medicine-Endocrinology, LUMC, Leiden, the Netherlands.
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