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Kim S, Kim M, Kodra A. Risks and Benefits of Device-Assisted Treatment of Pulmonary Embolism. Int J Angiol 2024; 33:101-106. [PMID: 38846990 PMCID: PMC11152619 DOI: 10.1055/s-0044-1782535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2024] Open
Abstract
Pulmonary embolism (PE) is a common disease associated with significant morbidity and mortality. Despite the familiarity with this disease, the best treatment remains undefined. Traditionally, treatment of PE has involved a choice of anticoagulation, thrombolysis, or surgery. However, the debate over pharmacologic versus mechanical treatment of acute PE reared up again with the advent of user-friendly mechanical and aspiration thrombectomy technologies. This is especially true for submassive PE, which is an area for potential growth both for understanding the pathophysiology of the disease process and management. Multiple devices are available for treatment of PE. Understanding the risks and benefits of each device is paramount in the complex management of PE.
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Affiliation(s)
- Sofia Kim
- Department of Cardiology, Northwell Health Lenox Hill Hospital, New York
| | - Michael Kim
- Department of Cardiology, Northwell Health Lenox Hill Hospital, New York
| | - Arber Kodra
- Department of Cardiology, Northwell Health Lenox Hill Hospital, New York
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2
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Germini F, Al-Haimus F, Hu Y, Mondoux S, Ibrahim Q, Chan N, Ikesaka R, Klyn J, Clayton N, Thabane L, de Wit K. Implementation, Clinical Benefit and Safety of a D-Dimer-Focused Pulmonary Embolism Testing Pathway in the Emergency Department. Ann Emerg Med 2024:S0196-0644(24)00156-2. [PMID: 38661619 DOI: 10.1016/j.annemergmed.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 02/26/2024] [Accepted: 03/12/2024] [Indexed: 04/26/2024]
Abstract
STUDY OBJECTIVE Computed tomography pulmonary angiogram (CTPA) is overused during pulmonary embolism (PE) testing in the emergency department (ED), whereas prediction rules and D-dimer are underused. We report the adherence, clinical benefit, and safety of a D-dimer-only strategy to guide need for PE imaging in the ED. METHODS This was a prospective multicenter implementation study in 2 EDs with historical and external controls. Patients with suspected PE underwent D-dimer testing and imaging (CTPA or ventilation-perfusion scan) when D-dimer levels were 500 ng/mL or more. PE was ruled out if D-dimer was less than 500 ng/mL or with negative imaging. The primary implementation outcome was the proportion of patients tested for PE in adherence with the pathway. The primary clinical benefit outcome was the proportion of patients tested for PE who received pulmonary imaging. The primary safety outcome was diagnosis of PE in the 30 days following negative PE testing postimplementation. RESULTS Between January 2018 and June 2021, 16,155 patients were tested for PE, including 33.4% postimplementation, 30.7% preimplementation, and 35.9% in an external control site. Adherence with the D-dimer-only pathway was 97.6% (adjusted odds ratio (aOR) post- versus preimplementation 5.26 (95% confidence interval 1.70 to 16.26). There was no effect on the proportion undergoing PE imaging. Imaging yield increased aOR 4.89 (1.17 to 20.53). Two cases of PE (0.04%; 0.01% to 0.16%) were diagnosed within 30 days. CONCLUSION In this Canadian ED study, the uptake of a D-dimer-only PE testing strategy was high. Implementation was associated with higher imaging yield and a D-dimer level of less than 500 ng/mL safely excluded PE.
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Affiliation(s)
- Federico Germini
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Fayad Al-Haimus
- Division of Emergency Medicine, Department of Medicine, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Yang Hu
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Shawn Mondoux
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Quazi Ibrahim
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Noel Chan
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Rick Ikesaka
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Joshua Klyn
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Natasha Clayton
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada; Schools of Nursing and Rehabilitation Sciences, McMaster University, Hamilton, ON, Canada; Departments of Surgery and Family Medicine, McMaster University, Hamilton, ON, Canada; Biostatistics Unit, Father Sean O'Sullivan Research Centre, St Joseph's Healthcare, Hamilton, ON, Canada; Departments of Paediatrics and Anaesthesia, McMaster University, Hamilton, ON, Canada; Faculty of Health Sciences, University of Johannesburg, Johannesburg, South Africa
| | - Kerstin de Wit
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Emergency Medicine, Queen's University, Kingston, ON, Canada.
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3
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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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4
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Opitz CF, Meyer FJ. Pulmonary Embolism: An Update Based on the Revised AWMF-S2k Guideline. Hamostaseologie 2024; 44:111-118. [PMID: 38688269 DOI: 10.1055/s-0044-1779011] [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: 05/02/2024] Open
Abstract
Pulmonary embolism (PE) is the third most common acute cardiovascular disease. The risk of PE increases with age and mortality is high. Patients are stratified into hemodynamically stable versus unstable patients, as this has important implications for diagnosis and therapy. Since clinical signs and symptoms of acute PE are nonspecific, the clinical likelihood of PE is estimated to guide diagnostic pathways. D-dimer testing is performed in hemodynamically stable patients with low or intermediate probability of PE and the visualization of thromboembolism and its sequelae is commonly achieved with computed tomography pulmonary angiography (CTPA), supplemented by ultrasound techniques. With confirmed PE, another risk stratification estimates disease severity and defines intensity and setting of the ensuing treatment. The therapeutic spectrum ranges from outpatient treatment with initial oral anticoagulation to thrombolytic or interventional treatment in the intensive care unit or catheterization laboratory. In single cases, even acute surgical thrombectomy is attempted.
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Affiliation(s)
| | - F Joachim Meyer
- Lungenzentrum München (Bogenhausen-Harlaching), München Klinik gGmbH, Sanatoriumsplatz 2, München, Germany
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Al Jalbout N, Ma I, Shokoohi H, McFadden K, Kabrhel C, Giordano N, Liteplo A. A Novel Tool for Predicting an Abnormal Echocardiogram in Patients with Pulmonary Embolism: The PEACE Score. J Emerg Med 2024; 66:e403-e412. [PMID: 38311529 DOI: 10.1016/j.jemermed.2023.11.011] [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: 04/27/2023] [Revised: 11/09/2023] [Accepted: 11/16/2023] [Indexed: 02/06/2024]
Abstract
BACKGROUND Transthoracic echocardiography (TTE) is an essential tool for risk-stratifying patients with pulmonary embolism (PE), but its availability is limited, often requiring hospitalization. Minimal research exists evaluating clinical and laboratory criteria to predict lack of abnormal TTE findings. OBJECTIVE We aimed to identify predictors associated with abnormal TTE results in patients with PE to potentially identify those safe for early discharge. METHODS In this retrospective study, we analyzed an existing database of patients with venous thromboembolism (VTE) at two academic emergency departments, including adult patients with confirmed PE who underwent TTE. The primary goal was to develop and validate a score predicting abnormal TTE, defined as presence of one of the following: right ventricle (RV) dilatation or hypokinesis, septal flattening, right heart thrombus in transit, or ejection fraction < 50%. Variables were demographic characteristics, symptoms, computed tomography (CT) RV strain, troponin T, and N-terminal prohormone of brain natriuretic peptide (NTproBNP). Stepwise logistic regression was used to identify variables independently associated with abnormal TTE. Model discrimination was evaluated using area under the curve (AUC) of the receiver operating characteristic curve. A clinical prediction rule was developed. RESULTS 530 of 2235 patients were included; 56% (297 of 530) had an abnormal TTE. The following six variables were independently associated with abnormal TTE: dyspnea, dizziness, troponin T ≥ 0.1 ng/mL, NTproBNP > 900 pg/mL, CT RV strain, and nonsubsegmental PE. A clinical prediction rule using these six criteria yielded scores between 0 and 7, performing well with AUC of 0.80 (95% CI 0.79-0.80). A score of 1 was 99.7% sensitive in identifying no abnormality. A score ≥ 5 was 98% specific for an abnormality. CONCLUSIONS The PEACE (Pulmonary Embolism and Abnormal Cardiac Echocardiogram) criteria, composed of six variables, is highly effective in predicting abnormal TTE in patients with PE, potentially identifying who is safe for early discharge from the hospital.
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Affiliation(s)
- Nour Al Jalbout
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Irene Ma
- Department of Internal Medicine, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Hamid Shokoohi
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kathleen McFadden
- Department of Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Christopher Kabrhel
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nicholas Giordano
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, Boston, Massachusetts
| | - Andrew Liteplo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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6
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Woo C, Sun W, Thein P, Chong MY, Tan E, Junckerstorff R. Preemptive anticoagulation of pulmonary embolism. Intern Med J 2024; 54:242-249. [PMID: 37490553 DOI: 10.1111/imj.16174] [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: 04/20/2022] [Accepted: 06/06/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND Pulmonary embolism (PE) is a life-threatening disease where preemptive anticoagulation is recommended by guidelines for patients with intermediate to high pretest risk of PE. AIMS The primary objective of our study was to describe the use of preemptive anticoagulation from the emergency department (ED) or inpatient wards stratified by risk assessment score. METHODS We performed a retrospective observational cohort study of consecutive patients undergoing computed tomography pulmonary angiography (CTPA) for investigation of PE. Patients were classified as either ED patients or hospital ward patients based on where the CTPA was requested. The pretest risk of PE was calculated using the Revised Geneva Score (RGS) and patients were divided into low and intermediate to high risk. RESULTS A total of 392 consecutive patients who underwent CTPA at Monash Health were reviewed. There were 108 (27.6%) patients who were categorised as low risk (RGS 0-3) and 284 (72.4%) categorised as intermediate to high risk (RGS >3). There were 29 (7.4%) patients overall who received preemptive anticoagulation. Diagnostic yield of CTPA in the ED was low, with only four of 144 (2.8%) CTPA scans positive for PE. The yield of CTPA was higher in ward patients, with 63 of 248 (25.4%) being diagnostic of PE. CONCLUSIONS The use of preemptive anticoagulation for suspected PE was uncommon and was not influenced by the pretest probability of PE as determined by a validated clinical prediction tool. This may reflect concerns regarding haemorrhagic complications without any clear evidence of benefit. Diagnostic yield of CTPA performed in the ED was low.
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Affiliation(s)
- Christopher Woo
- Department of Medicine, Monash Health, Melbourne, Victoria, Australia
| | - Wei Sun
- Department of Medicine, Monash Health, Melbourne, Victoria, Australia
| | - Paul Thein
- Department of Medicine, Monash Health, Melbourne, Victoria, Australia
| | - Mae Yi Chong
- Department of Medicine, Monash Health, Melbourne, Victoria, Australia
| | - Ethan Tan
- Department of Medicine, Monash Health, Melbourne, Victoria, Australia
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Chiang P, Robert-Ebadi H, Perrier A, Roy PM, Sanchez O, Righini M, Le Gal G. Pulmonary embolism risk stratification: external validation of the 4-level Clinical Pretest Probability Score (4PEPS). Res Pract Thromb Haemost 2024; 8:102348. [PMID: 38444614 PMCID: PMC10912690 DOI: 10.1016/j.rpth.2024.102348] [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: 03/14/2023] [Revised: 12/30/2023] [Accepted: 01/30/2024] [Indexed: 03/07/2024] Open
Abstract
Background The 4-level clinical pretest probability score (4PEPS) was recently introduced as a clinical decision rule for the diagnosis of pulmonary embolism (PE). Based on the score, patients are classified into clinical pretest probability categories (c-PTP). The "very low" category aims at excluding PE without further testing; "low" and "moderate" categories require D-dimer testing with specific thresholds, while patients with a "high" pretest directly proceed to imaging. Objectives To provide further external validation of the 4PEPS model. Methods The 4PEPS was applied to a previously collected prospective database of 756 patients with clinically suspected PE enrolled from European emergency departments in 2002 to 2003. The safety threshold for the failure rate in our study was calculated at 1.95% based on a 26% prevalence of PE in our study, as per the International Society on Thrombosis and Haemostasis Scientific and Standardization Committee guidance. Results Patients were classified as follows: 90 (12%) in the very low c-PTP group, of whom 5 (5.6%; 95% CI, 2.4%-12.4%) had PE; 363 (49%) in the low c-PTP group, of whom 34 had PE (9.4%); 246 (34%) in the moderate c-PTP group, of whom 124 (50%) had PE; and 35 (5%) in the high c-PTP group of whom 30 (86%) had PE. Overall, the failure rate of the 4PEPS was 9/734 (1.2%; 95% CI, 0.59%-2.23%) Overall, 9 out of 734 patients (1.2%; 95% CI, 0.59%-2.23%) were diagnosed with PE despite a negative 4PEPS rule; 5 (5.6%) from the very low c-PTP group, 3 (1.4%) in the low c-PTP group, and 1 (3.2%) in the moderate c-PTP group. Conclusion We provide external validation data of the 4PEPS. In this high-prevalence cohort (26% prevalence), PE prevalence in the very low-risk group was higher than expected. A prospective validation study is needed before implementing the 4PEPS model in routine clinical practice.
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Affiliation(s)
- Philip Chiang
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Ontario, Canada
| | - Helia Robert-Ebadi
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Arnaud Perrier
- Department of Medicine, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Pierre-Marie Roy
- Department of Emergency Medicine, University Hospital of Angers, Angers, France
| | - Olivier Sanchez
- Department of Respiratory Disease, Hôpital Européen Georges Pompidou, Hôpital de l'Assistance publique - Hôpitaux de Paris, Université Paris Descartes, Paris, France
| | - Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Grégoire Le Gal
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Ontario, Canada
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Schell R, Alban F, Frey N, Erbel C. Spontaneous blood pressure reduction of previously hypertensive patients as a symptom of central pulmonary artery embolism. Clin Res Cardiol 2023:10.1007/s00392-023-02315-z. [PMID: 37796318 DOI: 10.1007/s00392-023-02315-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 09/19/2023] [Indexed: 10/06/2023]
Affiliation(s)
- R Schell
- Department of Internal Medicine III, Division of Cardiology, University Hospital Heidelberg, Ruprecht-Karl University Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
- DZHK (German Center for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Heidelberg, Germany.
| | - F Alban
- Department of Internal Medicine III, Division of Cardiology, University Hospital Heidelberg, Ruprecht-Karl University Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - N Frey
- Department of Internal Medicine III, Division of Cardiology, University Hospital Heidelberg, Ruprecht-Karl University Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| | - C Erbel
- Department of Internal Medicine III, Division of Cardiology, University Hospital Heidelberg, Ruprecht-Karl University Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
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Götzinger F, Lauder L, Sharp ASP, Lang IM, Rosenkranz S, Konstantinides S, Edelman ER, Böhm M, Jaber W, Mahfoud F. Interventional therapies for pulmonary embolism. Nat Rev Cardiol 2023; 20:670-684. [PMID: 37173409 PMCID: PMC10180624 DOI: 10.1038/s41569-023-00876-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/30/2023] [Indexed: 05/15/2023]
Abstract
Pulmonary embolism (PE) is the leading cause of in-hospital death and the third most frequent cause of cardiovascular death. The clinical presentation of PE is variable, and choosing the appropriate treatment for individual patients can be challenging. Traditionally, treatment of PE has involved a choice of anticoagulation, thrombolysis or surgery; however, a range of percutaneous interventional technologies have been developed that are under investigation in patients with intermediate-high-risk or high-risk PE. These interventional technologies include catheter-directed thrombolysis (with or without ultrasound assistance), aspiration thrombectomy and combinations of the aforementioned principles. These interventional treatment options might lead to a more rapid improvement in right ventricular function and pulmonary and/or systemic haemodynamics in particular patients. However, evidence from randomized controlled trials on the safety and efficacy of these interventions compared with conservative therapies is lacking. In this Review, we discuss the underlying pathophysiology of PE, provide assistance with decision-making on patient selection and critically appraise the available clinical evidence on interventional, catheter-based approaches for PE treatment. Finally, we discuss future perspectives and unmet needs.
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Affiliation(s)
- Felix Götzinger
- Clinic of Cardiology, Angiology and Intensive Care Medicine, University Hospital Homburg, Saarland University, Homburg, Germany
| | - Lucas Lauder
- Clinic of Cardiology, Angiology and Intensive Care Medicine, University Hospital Homburg, Saarland University, Homburg, Germany
| | - Andrew S P Sharp
- Department of Cardiology, University Hospital of Wales, Cardiff, UK
- Cardiff University, Cardiff, UK
| | - Irene M Lang
- Department of Cardiology, Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Stephan Rosenkranz
- Department of Cardiology - Internal Medicine III, Cologne University Heart Center, Cologne, Germany
- Cologne Cardiovascular Research Center (CCRC), Cologne University Heart Center, Cologne, Germany
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Elazer R Edelman
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Michael Böhm
- Clinic of Cardiology, Angiology and Intensive Care Medicine, University Hospital Homburg, Saarland University, Homburg, Germany
| | - Wissam Jaber
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Felix Mahfoud
- Clinic of Cardiology, Angiology and Intensive Care Medicine, University Hospital Homburg, Saarland University, Homburg, Germany.
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA.
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10
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Robert-Ebadi H, Roy PM, Sanchez O, Verschuren F, Le Gal G, Righini M. External validation of the PEGeD diagnostic algorithm for suspected pulmonary embolism in an independent cohort. Blood Adv 2023; 7:3946-3951. [PMID: 36521170 PMCID: PMC10410134 DOI: 10.1182/bloodadvances.2022007729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 10/18/2022] [Accepted: 10/18/2022] [Indexed: 12/23/2022] Open
Abstract
Sequential diagnostic algorithms are used in the case of suspected pulmonary embolism (PE). The PEGeD study proposed a new diagnostic strategy to reduce the use of computed tomography pulmonary angiography (CTPA). We aimed to externally validate this diagnostic strategy in an independent cohort. We analyzed data from 3 prospective studies of outpatients with suspected PE. As per the PEGeD algorithm, patients were classified as having a low, moderate, or high clinical pretest probability (C-PTP). PE was excluded with a D-dimer <1000 ng/mL in case of low C-PTP and <500 ng/mL in case of moderate C-PTP. We assessed the yield and safety of this approach and compared them with those of previously validated algorithms. Among the 3308 evaluated patients, 1615 (49%) patients could have had PE excluded according to the PEGeD algorithm, without the need for imaging. Of these patients, 38 (2.3%; 95% confidence interval [CI], 1.7-3.2) were diagnosed with a symptomatic PE at initial testing or during the 3-month follow-up. On further analysis, 36 patients out of these 38 patients had a positive age-adjusted D-dimer. The risk of venous thromboembolic events among the 414 patients with a D-dimer <1000 ng/mL but above the age-adjusted D-dimer cut-off was 36 of 414 (8.7%; 95% CI, 6.4-11.8). We provide external validation of the PEGeD algorithm in an independent cohort. Compared with standard algorithms, the PEGeD decreased the number of CTPA examinations. However, caution is required in patients with a low C-PTP and a D-dimer <1000 ng/mL but above their age-adjusted D-dimer cut-off.
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Affiliation(s)
- Helia Robert-Ebadi
- Division of Angiology and Hemostasis and Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Pierre-Marie Roy
- Department of Emergency Medicine, University Hospital of Angers, Angers, France
| | - Olivier Sanchez
- Department of Respiratory Disease, Hôpital Européen Georges Pompidou, APHP, and Université Paris Descartes, Paris, France
| | - Frank Verschuren
- Emergency Department, Saint-Luc University Hospital, Brussels, Belgium
| | - Grégoire Le Gal
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Marc Righini
- Division of Angiology and Hemostasis and Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
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11
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Wikan VE, Tøndel BG, Morelli VM, Brodin EE, Brækkan SK, Hansen JB. Diagnostic Blood Biomarkers for Acute Pulmonary Embolism: A Systematic Review. Diagnostics (Basel) 2023; 13:2301. [PMID: 37443693 DOI: 10.3390/diagnostics13132301] [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: 05/16/2023] [Revised: 06/22/2023] [Accepted: 07/04/2023] [Indexed: 07/15/2023] Open
Abstract
(1) Background: The current diagnostic algorithm for acute pulmonary embolism (PE) is associated with the overuse of CT pulmonary angiography (CTPA). An additional highly specific blood test could potentially lower the proportion of patients with suspected PE that require CTPA. The aim was to summarize the literature on the diagnostic performance of biomarkers of patients admitted to an emergency department with suspected acute PE. (2) Methods: Medline and Embase databases were searched from 1995 to the present. The study selection process, data extraction, and risk of bias assessment were conducted by two reviewers. Eligibility criteria accepted all blood biomarkers except D-dimer, and CTPA was used as the reference standard. Qualitative data synthesis was performed. (3) Results: Of the 8448 identified records, only 6 were included. Eight blood biomarkers were identified, of which, three were investigated in two separate studies. Red distribution width and mean platelet volume were reported to have a specificity of ≥ 90% in one study, although these findings were not confirmed by other studies. The majority of the studies contained a high risk of selection bias. (4) Conclusions: The modest findings and the uncertain validity of the included studies suggest that none of the biomarkers identified in this systematic review have the potential to improve the current diagnostic algorithm for acute PE by reducing the overuse of CTPA.
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Affiliation(s)
- Vårin Eiriksdatter Wikan
- Thrombosis Research Group (TREC), Department of Clinical Medicine, UiT-The Arctic University of Norway, N-9037 Tromsø, Norway
| | - Birgitte Gladsø Tøndel
- Thrombosis Research Group (TREC), Department of Clinical Medicine, UiT-The Arctic University of Norway, N-9037 Tromsø, Norway
| | - Vânia Maris Morelli
- Thrombosis Research Group (TREC), Department of Clinical Medicine, UiT-The Arctic University of Norway, N-9037 Tromsø, Norway
- Thrombosis Research Center (TREC), Division of Internal Medicine, University Hospital of North Norway, N-9038 Tromsø, Norway
| | - Ellen Elisabeth Brodin
- Hematological Research Group, Division of Medicine, Akershus University Hospital, N-1478 Lørenskog, Norway
| | - Sigrid Kufaas Brækkan
- Thrombosis Research Group (TREC), Department of Clinical Medicine, UiT-The Arctic University of Norway, N-9037 Tromsø, Norway
- Thrombosis Research Center (TREC), Division of Internal Medicine, University Hospital of North Norway, N-9038 Tromsø, Norway
| | - John-Bjarne Hansen
- Thrombosis Research Group (TREC), Department of Clinical Medicine, UiT-The Arctic University of Norway, N-9037 Tromsø, Norway
- Thrombosis Research Center (TREC), Division of Internal Medicine, University Hospital of North Norway, N-9038 Tromsø, Norway
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Urriago-Osorio GA, Melo-Burbano LÁ, López-Van Den Berghe J, Muñoz-Córdoba AM, Daza-Arana JE, Contreras-Zúñiga E. Pulmonary Thromboembolism in Pregnancy: A Case Report and Literature Review. Open Access Emerg Med 2023; 15:217-225. [PMID: 37292453 PMCID: PMC10246571 DOI: 10.2147/oaem.s404941] [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: 02/11/2023] [Accepted: 04/18/2023] [Indexed: 06/10/2023] Open
Abstract
Data on the optimal diagnostic management of pregnant women with suspected pulmonary embolism are limited. Despite a lack of compelling evidence in some practices, clinical practice guidelines focus on the management of these patients. We present the case of a 24-year-old patient at 36 weeks of pregnancy in whom pulmonary thromboembolism (PTE) was diagnosed in a timely manner also with hemodynamic instability and echocardiographic images with clear involvement of the right cavities. She received thrombolytic therapy with alteplase 100 mg intravenously over 2 hours, which resulted in excellent outcomes for both the pregnant woman and fetus. Understanding the acute approach and management of these patients will improve our clinical practice; therefore, we reviewed a case report of a pregnant patient with high-risk PTE and compared it with current evidence. In conclusion, PE is a common disease with a high mortality rate during pregnancy. Therefore, having made a timely diagnosis using the relevant diagnostic aids and performing thrombolysis with rtPA increase the probability of survival in our patient, leading to successful results for both her and the fetus.
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Affiliation(s)
- Gustavo Andrés Urriago-Osorio
- Department of Health, Internal Medicine Specialization Program, Universidad Santiago de Cali, Santiago de Cali, Colombia
- Emergency Department, Clínica de Occidente S.A, Santiago de Cali, Colombia
| | - Luis Álvaro Melo-Burbano
- Department of Health, Internal Medicine Specialization Program, Universidad Santiago de Cali, Santiago de Cali, Colombia
- Emergency Department, Clínica de Occidente S.A, Santiago de Cali, Colombia
| | | | | | - Jorge Enrique Daza-Arana
- Department of Health, Internal Medicine Specialization Program, Universidad Santiago de Cali, Santiago de Cali, Colombia
- Health and Movement Research Group, Universidad Santiago de Cali, Santiago de Cali, Colombia
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13
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Duffy J, Berger FH, Cheng I, Shelton D, Galanaud JP, Selby R, Laing K, Fedorovsky T, Matelski J, Hall J. Implementation of the YEARS algorithm to optimise pulmonary embolism diagnostic workup in the emergency department. BMJ Open Qual 2023; 12:bmjoq-2022-002119. [PMID: 37217241 DOI: 10.1136/bmjoq-2022-002119] [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: 09/03/2022] [Accepted: 04/29/2023] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND Excessive use of CT pulmonary angiography (CTPA) to investigate pulmonary embolism (PE) in the emergency department (ED) contributes to adverse patient outcomes. Non-invasive D-dimer testing, in the context of a clinical algorithm, may help decrease unnecessary imaging but this has not been widely implemented in Canadian EDs. AIM To improve the diagnostic yield of CTPA for PE by 5% (absolute) within 12 months of implementing the YEARS algorithm. MEASURES AND DESIGN Single centre study of all ED patients >18 years investigated for PE with D-dimer and/or CTPA between February 2021 and January 2022. Primary and secondary outcomes were the diagnostic yield of CTPA and frequency of CTPA ordered compared with baseline. Process measures included the percentage of D-dimer tests ordered with CTPA and CTPAs ordered with D-dimers <500 µg/L Fibrinogen Equivalent Units (FEU). The balancing measure was the number of PEs identified on CTPA within 30 days of index visit. Multidisciplinary stakeholders developed plan- do-study-act cycles based on the YEARS algorithm. RESULTS Over 12 months, 2695 patients were investigated for PE, of which 942 had a CTPA. Compared with baseline, the CTPA yield increased by 2.9% (12.6% vs 15.5%, 95% CI -0.06% to 5.9%) and the proportion of patients that underwent CTPA decreased by 11.4% (46.4% vs 35%, 95% CI -14.1% to -8.8%). The percentage of CTPAs ordered with a D-dimer increased by 26.3% (30.7% vs 57%, 95% CI 22.2% 30.3%) and there were two missed PE (2/2695, 0.07%). IMPACT Implementing the YEARS criteria may safely improve the diagnostic yield of CTPAs and reduce the number of CTPAs completed without an associated increase in missed clinically significant PEs. This project provides a model for optimising the use of CTPA in the ED.
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Affiliation(s)
- Juliana Duffy
- Division of Emergency Medicine, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ferco Henricus Berger
- Department of Medical Imaging, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Ivy Cheng
- Division of Emergency Medicine, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Emergency Services, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Dominick Shelton
- Department of Emergency Services, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Family & Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jean-Philippe Galanaud
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Rita Selby
- Department of Laboratory Medicine & Pathobiology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Laboratory Medicine & Pathobiology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kristine Laing
- Department of Emergency Services, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Tali Fedorovsky
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - John Matelski
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Justin Hall
- Division of Emergency Medicine, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Emergency Services, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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14
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de Wit K, Al-Haimus F, Hu Y, Ikesaka R, Chan N, Ibrahim Q, Klyn J, Clayton N, Germini F. Comparison of YEARS and Adjust-Unlikely D-dimer Testing for Pulmonary Embolism in the Emergency Department. Ann Emerg Med 2023; 81:558-565. [PMID: 36371248 DOI: 10.1016/j.annemergmed.2022.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 09/05/2022] [Accepted: 09/19/2022] [Indexed: 11/12/2022]
Abstract
STUDY OBJECTIVE We prospectively assessed the diagnostic accuracy of YEARS and a modified age-adjusted clinical decision rule ("Adjust-Unlikely") for pulmonary embolism (PE) testing in the emergency department. METHODS This study was conducted in tertiary care Canadian emergency departments. When the D-dimer was <500 ng/ml, PE was excluded. Pulmonary imaging for PE was performed when the D-dimer was ≥500 ng/ml. Patients were followed for 30 days, and PE outcomes were independently adjudicated. Physicians systematically recorded the presence or absence of YEARS items (PE most likely, hemoptysis, signs of deep venous thrombosis) prior to D-dimer testing and imaging. We analyzed the diagnostic accuracy of YEARS and the "Adjust-Unlikely" rule. Age adjustment (age x 10 in those >50 years old) was applied in patients where PE was not the most likely diagnosis and 500 ng/ml threshold when PE was most likely. RESULTS One thousand seven hundred three patients were included, median age 62 (50, 74), 58% female, PE prevalence 8.0%. YEARS sensitivity for PE diagnosis was 92.6% (87.0, 96.0%) and specificity 45.0% (42.5, 47.5%). Adjust-Unlikely sensitivity was 100.0% (97.2, 100.0%) and specificity 32.4% (30.1, 34.8%). Posttest probability of PE in the group of patients with PE excluded by D-dimer between 500 ng/ml and the adjusted limit was 2.8% (1.6, 5.1%) for YEARS and 0.0% (0.0, 2.6%) for the "Adjust-Unlikely" rule. CONCLUSION The "Adjust-Unlikely" rule would modestly reduce imaging and identify all cases of PE. YEARS would substantially reduce imaging but miss 1 in 14 cases of PE.
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Affiliation(s)
- Kerstin de Wit
- Department of Emergency Medicine and Medicine, Queens University, Kingston, and Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
| | - Fayad Al-Haimus
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Yang Hu
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Rick Ikesaka
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Noel Chan
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Quazi Ibrahim
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Joshua Klyn
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Natasha Clayton
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Emergency Department, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Federico Germini
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, ON, Canada
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15
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Characteristics associated with diagnostic yield of imaging for deep venous thrombosis and pulmonary embolism in the emergency department, hospital, and office settings: An Optum Clinformatics claims database study (2015-2019). Thromb Res 2023; 224:4-12. [PMID: 36774701 DOI: 10.1016/j.thromres.2023.02.004] [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: 09/15/2022] [Revised: 01/28/2023] [Accepted: 02/03/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND Different patient characteristics influence the decision to order diagnostic imaging for deep venous thrombosis (DVT) and pulmonary embolism (PE) in different settings (emergency department (ED), hospital, and office). Diagnostic yield is defined as the proportion of tests that report positive results. We hypothesize different patient characteristics are associated with higher or lower diagnostic yield of imaging for DVT and PE in different settings. METHODS We used Optum Clinformatics™ national claims database (2015-2019) to assess the diagnostic yield of imaging for DVT and PE in three settings: (a) ED discharge, (b) Hospitalized, and (c) Office. We studied the patient characteristics associated with diagnostic yield using logistic regression. RESULTS Diagnostic imaging for DVT and PE was performed in 1,502,417 and 710,263 visits, respectively. Diagnostic yield for DVT and PE was 9.8 ± 0.1 % and 12.7 ± 0.1 %, respectively in the overall cohort. In the ED discharge, hospitalized, and office settings, diagnostic yield for DVT was 10.4 ± 0.1 %, 16.9 ± 0.1 %, and 6.5 ± 0.1 %, respectively, and that for PE 6.4 ± 0.1 %, 18.7 ± 0.1 %, and 8.8 ± 0.2 %, respectively. Of the patients who underwent imaging for DVT, higher diagnostic yield was more likely with thrombophilia, central venous access, and cancer. Of the patients who underwent imaging for PE, higher diagnostic yield was most likely with thrombophilia, respiratory failure, and heart failure or acute myocardial infarction. CONCLUSIONS In each setting, different patient characteristics influence the diagnostic yield of imaging for DVT and PE and can inform clinical practice. Judicious use of imaging for DVT and PE could reduce costs and avoid exposure to radiation and contrast.
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Computed Tomography Angiography for Detection of Pulmonary Embolism in Western Australia Shows Increasing Use with Decreasing Diagnostic Yield. J Clin Med 2023; 12:jcm12030980. [PMID: 36769627 PMCID: PMC9917579 DOI: 10.3390/jcm12030980] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 01/23/2023] [Accepted: 01/25/2023] [Indexed: 01/31/2023] Open
Abstract
(1) Background: Pulmonary embolism (PE) can be fatal. Computed tomography pulmonary angiography (CTPA) can accurately diagnose PE, but it should be used only when reasonable pre-test probability exists. Overtesting with CTPA exposes patients to excess ionizing radiation and contrast media, while PE overdiagnosis leads to the treatment of small emboli unlikely to cause harm. This study assessed trends in CTPA use and diagnostic yield. We also assessed trends in PE hospitalizations and mortality to indicate PE severity. (2) Methods: Analysis of Western Australian linked administrative data for 2003-2015 including hospitalizations, emergency department (ED) attendances, and CTPA performed at hospitals. Age-sex standardized trends were calculated for CTPA use, PE hospitalizations, and mortality (as a proxy for severity). Logistic regression assessed diagnostic yield of CTPA following unplanned ED presentations. (3) Results: CTPA use increased from 3.3 per 10,000 person-years in 2003 (95% CI 3.0-3.6) to 17.1 per 10,000 person-years (16.5-17.7) in 2015. Diagnostic yield of CTPA increased from 12.7% in 2003 to 17.4% in 2005, declining to 12.2% in 2015 (p = 0.049). PE hospitalizations increased from 3.8 per 10,000 (3.5-4.1) in 2003 to 5.2 per 10,000 (4.8-5.5) in 2015. Mortality remained constant at 0.50 per 10,000 (0.39-0.62) in 2003 and 0.42 per 10,000 (0.32-0.51) in 2015. (4) Conclusions: CTPA increased from 2003 to 2015, while diagnostic yield decreased, potentially indicating overtesting. PE mortality remained constant despite increasing hospitalizations, likely indicating a higher proportion of less severe cases. As treatment can be harmful, this could represent overdiagnosis.
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17
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Zhu YJ, Zhu XJ, Cheng CY. Screening Pulmonary Embolism in Patients with Recent Onset Dyspnea: Should We Do More? JOURNAL OF THROMBOSIS AND HAEMOSTASIS : JTH 2023; 21:21-23. [PMID: 36695391 DOI: 10.1016/j.jtha.2022.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 10/22/2022] [Accepted: 10/27/2022] [Indexed: 01/11/2023]
Affiliation(s)
- Yong-Jian Zhu
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xi-Jie Zhu
- Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chun-Yan Cheng
- Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Prandoni P, Lensing AWA, Prins MH, Ciammaichella M, Pirillo S, Pace F, Zalunardo B, Bottino F, Ageno W, Muiesan ML, Forlin M, Depietri L, Bova C, Costantini N, Caviglioli C, Migliaccio L, Noventa F, Levi M, Davidson BL, Palareti G. Prevalence of pulmonary embolism among patients with recent onset of dyspnea on exertion. A cross-sectional study. JOURNAL OF THROMBOSIS AND HAEMOSTASIS : JTH 2023; 21:68-75. [PMID: 36695397 DOI: 10.1016/j.jtha.2022.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 09/21/2022] [Accepted: 09/22/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Exertional dyspnea is a frequently encountered complaint in clinical practice. However, the prevalence of pulmonary embolism (PE) among patients with dyspnea on exertion has not been reported. OBJECTIVE The objective of this study was to assess the prevalence of objectively confirmed PE among consecutive patients visiting an emergency department because of recent onset of exertional dyspnea. METHODS Patients aged ≤75 years with recent (<1 month) marked exertional dyspnea had a systematic workup for PE, irrespective of concomitant signs or symptoms of venous thromboembolism and alternative explanations for dyspnea. PE was excluded on the basis of a low pretest clinical probability and normal age-adjusted D-dimer. All other patients had computed tomography pulmonary angiography. An interim analysis after inclusion of 400 patients would stop recruitment if the 95% confidence interval (CI) of the PE prevalence had a lower limit exceeding 20%. RESULTS The study was prematurely terminated after the inclusion of 417 patients. In 134 patients (32.1%), PE was excluded based on low clinical probability and normal D-dimer. PE was found in 134 (47.3%) of the remaining 283 patients, for an overall prevalence of 32.1% (95% CI, 27.8-36.8). PE was present in 40 of 204 (19.6%) patients without other findings suspicious for PE and in 94 of 213 patients (44.1%) with such findings. PE involved a main pulmonary artery in 37% and multiple lobes in 87% of the patients. CONCLUSION The angiographic demonstration of PE is common in patients presenting with recent onset of marked exertional dyspnea, including 20% without other findings suggesting pulmonary embolism.
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Affiliation(s)
| | | | - Martin H Prins
- Department of Clinical Epidemiology, University of Maastricht, The Netherlands
| | | | - Silvana Pirillo
- Department of Radiology, S. Giovanni-Addolorata Hospital, Rome, Italy
| | | | - Beniamino Zalunardo
- Angiology Unit and Emergency Medicine Unit, San Giacomo Hospital, Castelfranco Veneto, Italy
| | | | - Walter Ageno
- Department of Internal Medicine, University of Insubria, Varese, Italy
| | - Maria L Muiesan
- Department of Internal Medicine, University of Brescia and ASST Spedali Civili, Brescia, Italy
| | - Marco Forlin
- Emergency Department, Civic Hospital, Pieve di Soligo, Italy
| | - Luca Depietri
- Cardiovascular Medicine, Civic Hospital, Reggio Emilia, Italy
| | - Carlo Bova
- Department of Internal Medicine, Civic Hospital, Cosenza, Italy
| | | | - Cosimo Caviglioli
- Emergency Department, University of Firenze Careggi, Florence, Italy
| | | | - Franco Noventa
- Department of Molecular Medicine, University of Padua, Padua, Italy
| | - Marcel Levi
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Bruce L Davidson
- Washington State University Floyd College of Medicine, Seattle, Washington State, USA
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Karimialavijeh E, Khaksar A, Pishgahi G, Sadat Hashemi M, Jalali A. Tricuspid Annular Plane Systolic Excursion (TAPSE) Measurement by Emergency Medicine Residents in Patients Suspected of Pulmonary Emboli. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2022; 41:2079-2085. [PMID: 34825725 DOI: 10.1002/jum.15892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 10/21/2021] [Accepted: 10/29/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES We aimed to evaluate the ability of emergency medicine (EM) residents to measure tricuspid annular plane systolic excursion (TAPSE) by M-Mode ultrasound. METHODS Four EM residents with prior focused cardiac ultrasound (FOCUS) experience participated in 10 hours of hands-on training and then performed TAPSE measurements in adult patients at high risk of having pulmonary emboli (PE) between December 2020 and April 2021. Patients underwent bedside echocardiography by cardiology residents, and a CT pulmonary angiogram (CTPA) was performed to confirm the diagnosis. The agreement between EM and cardiology residents was assessed by intraclass correlation coefficient (ICC). RESULTS Sixty-six patients were included (mean age = 58.7 ± 16.7 years), of which 28 patients (42.8%) had positive CTPA. The mean TAPSE, measured by EM residents was 16.36 ± 1.59 mm in the PE positive group and 21.68 ± 2.87 mm in the PE negative group (P-value = <.0001). The mean ± SD TAPSE, measured by cardiology residents, was 17.7 ± 1.98 mm in the PE group and 22.5 ± 3.6 mm in the PE negative group (P-value = <.0001). There was significant agreement between EM and cardiology residents in terms of measuring TAPSE (ICC = 0.91, 95% confidence interval [CI] = 0.80-0.95). The receiver operating characteristic (ROC) curves of TAPSE for diagnosing PE revealed that TAPSE, measured by EM residents, had a high level of accuracy (area under the ROC curve [AUC] = 0.93, 95% CI, 0.878-0.99). CONCLUSIONS EM residents can perform M-Mode TAPSE measurement in suspected PE cases after 10 hours of hands-on training. TAPSE measurement should be added to routine FOCUS protocols, especially when there is suspicion of PE.
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Affiliation(s)
- Ehsan Karimialavijeh
- Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Afshin Khaksar
- Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Ghasem Pishgahi
- Scientific Research Center (SSRC), Tehran University of Medical Sciences, Tehran, Iran
| | - Mozhgan Sadat Hashemi
- Scientific Research Center (SSRC), Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Jalali
- Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
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20
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Affiliation(s)
- Susan R Kahn
- From Lady Davis Institute at Jewish General Hospital and the Department of Medicine, McGill University, Montreal (S.R.K.), the Department of Emergency Medicine, Queen's University, Kingston, ON (K.W.), and the Departments of Medicine and Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON (K.W.) - all in Canada
| | - Kerstin de Wit
- From Lady Davis Institute at Jewish General Hospital and the Department of Medicine, McGill University, Montreal (S.R.K.), the Department of Emergency Medicine, Queen's University, Kingston, ON (K.W.), and the Departments of Medicine and Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON (K.W.) - all in Canada
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21
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Westafer LM, Vinson DR. Risk for Recurrent Venous Thromboembolism in Patients With Subsegmental Pulmonary Embolism Managed Without Anticoagulation. Ann Intern Med 2022; 175:W43. [PMID: 35436438 DOI: 10.7326/l22-0037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Lauren M Westafer
- University of Massachusetts Chan Medical School-Baystate, Amherst, Massachusetts
| | - David R Vinson
- The Permanente Medical Group and Kaiser Permanente Division of Research, Oakland, California
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22
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Redinger K, Rozin E, Schiller T, Zhen A, Vos D. The Impact of Pop-Up Clinical Electronic Health Record Decision Tools on Ordering Pulmonary Embolism Studies in the Emergency Department. J Emerg Med 2021; 62:103-108. [PMID: 34649762 DOI: 10.1016/j.jemermed.2021.09.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 09/01/2021] [Accepted: 09/11/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Emergency physicians make time-sensitive care decisions for life threatening diagnoses and utilize evidence-based decision rules and testing with high sensitivity to ensure that critical diagnoses are not missed. Current literature suggests that there is over testing for pulmonary embolism in the emergency department. OBJECTIVES This study aimed to determine whether the addition of a pop-up notification of the Modified Wells Criteria into the workflow would impact the number of total orders for computed tomography pulmonary angiography (CTPA) or the diagnostic yield of those studies. METHODS This study was a retrospective observational study comparing CTPA utilization rates and diagnostic yield among physicians at a single academic emergency department in the 1 year prior and 1 year post implementation of an active electronic health recored (EHR) pop-up of Modified Well's scoring when ordering a CTPA. RESULTS CTPA utilization rates were statistically equivalent, p <0.0001 within a 0.5% equivalence margin, during the pre and post intervention years. The observed difference was 0.1% (95% CI -0.02%, 0.21%). Despite proving equivalence in the rates of CTPA studies ordered, the diagnostic yield, however, was significantly different (p = 0.001), 32.35% in the pre-intervention year compared to 41.60% in the post-intervention year. CONCLUSION There are many barriers to the implementation of successful EHR alerts. These findings support and validate previous studies that have shown a higher diagnostic yield of CT angiography for pulmonary embolism after implementation of active alerts integrated into the EHR with ordering studies. These tools are effective quality improvement initiatives, and their use should be encouraged.
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Affiliation(s)
- Kathryn Redinger
- Department of Emergency Medicine, Western Michigan University Homer Stryker M.D. School of Medicine.
| | - Emily Rozin
- Department of Emergency Medicine, Western Michigan University Homer Stryker M.D. School of Medicine
| | - Timothy Schiller
- Department of Emergency Medicine, Western Michigan University Homer Stryker M.D. School of Medicine
| | - Andrew Zhen
- Department of Emergency Medicine, Western Michigan University Homer Stryker M.D. School of Medicine
| | - Duncan Vos
- Department of Biostatistics, Western Michigan University Homer Stryker M.D. School of Medicine
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