1
|
Baumgartner C, Tritschler T, Aujesky D. Subsegmental Pulmonary Embolism. Hamostaseologie 2024; 44:197-205. [PMID: 37871632 DOI: 10.1055/a-2163-3111] [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: 10/25/2023] Open
Abstract
Subsegmental pulmonary embolism (SSPE) is increasingly diagnosed with the growing use and technological advancements of multidetector computed tomography pulmonary angiography. Its diagnosis is challenging, and some presumed SSPE may actually represent imaging artifacts. Indirect evidence and results from small observational studies suggest that SSPE may be more benign than more proximal pulmonary embolism, and may thus not always require treatment. Therefore, guidelines suggest to consider a management strategy without anticoagulation in selected patients with SSPE at low risk of recurrent venous thromboembolism (VTE), in whom proximal deep vein thrombosis is excluded. Recently, a large prospective study among low-risk patients with SSPE who were left untreated showed a higher VTE recurrence risk than initially deemed acceptable by the investigators, and thus was prematurely interrupted after recruitment of 97% of the target population. However, the risk-benefit ratio of anticoagulation for low-risk patients with SSPE remains unclear, and results from randomized trials are needed to answer the question about their optimal management.
Collapse
Affiliation(s)
- Christine Baumgartner
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Tobias Tritschler
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| |
Collapse
|
2
|
Glazier CR, Baciewicz FA. Epidemiology, Etiology, and Pathophysiology of Pulmonary Embolism. Int J Angiol 2024; 33:76-81. [PMID: 38846994 PMCID: PMC11152621 DOI: 10.1055/s-0044-1785487] [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
Over the last 20 years, there has been a progressive increase in the incidence of pulmonary embolism (PE) diagnosis in the United States, Europe, and Australia. Increased use of computed tomography pulmonary angiography has likely contributed in part to this rising incidence. However, it is pertinent to note that the burden of comorbidities associated with PE, such as malignancy, obesity, and advanced age, has also increased over the past 20 years. Time-trend analysis in North American, European, and Asian populations suggests that mortality rates associated with PE have been declining. The reported improved survival rates in PE over the past 20 years are likely, at least in part, to be the result of better adherence to guidelines, improved risk stratification, and enhanced treatment. Factors contributing to the development of venous thromboembolism (VTE) include stasis of blood, hypercoagulability, endothelial injury, and inflammation. In 70 to 80% of cases of PE, the thrombi embolizes from the proximal deep veins of the lower extremities and pelvis. Strong risk factors for VTE include lower extremity fractures and surgeries, major trauma, and hospitalization within the previous 3 months for acute myocardial infarction or heart failure with atrial fibrillation. Acute PE causes several pathophysiological responses including hypoxemia and right ventricle (RV) failure. The latter is a result of pulmonary artery occlusion and associated vasoconstriction. Hemodynamic compromise from RV failure is the principal cause of poor outcome in patients with acute PE.
Collapse
Affiliation(s)
| | - Frank A. Baciewicz
- Division of Cardiothoracic Surgery, Wayne State University School of Medicine, Detroit, Michigan
| |
Collapse
|
3
|
Teissandier D, Roussel M, Bannelier H, Freund Y, Catoire P. Contemporary approaches to pulmonary embolism diagnosis: a clinical review. Clin Exp Emerg Med 2024; 11:127-135. [PMID: 38368878 PMCID: PMC11237265 DOI: 10.15441/ceem.23.157] [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: 11/07/2023] [Revised: 02/02/2024] [Accepted: 02/05/2024] [Indexed: 02/20/2024] Open
Abstract
The optimal diagnosis strategy for pulmonary embolism (PE) in the emergency department (ED) remains complex. This review summarizes PE diagnosis with clinical presentation, decision rules and investigations for acute PE. This review was performed using studies published between January 1, 2010, and September 1, 2023. PE should be considered in ED in patients with chest pain, shortness of breath, syncope or signs of deep veinous thrombosis. Definitive diagnosis of PE relies on thoracic imaging, with the use of chest tomographic pulmonary angiogram or ventilation-perfusion lung scintigraphy. To limit the continuous increased use of chest imaging, the clinical probability should be the first step for PE workup. The pulmonary embolism rule-out criteria (PERC) can rule out PE at this stage. If not, for low or intermediate probability, several clinical decision rules have been validated, either by ruling out PE on clinical signs, or by raising D-dimer thresholds (YEARS or PEGeD [Pulmonary Embolism Graduated D-Dimer] criteria) or by combination of these different rules. It is recommended that patients with a high clinical probability of PE should undergo chest imaging without the need for D-dimer testing. The PE diagnostic approach can be tailored in specific populations such as pregnant, younger, COVID-19, or cancer patients. PE diagnosis workup illustrates the complexity of modern probabilistic-based approaches of decision-making in medicine. It is recommended to use a Bayesian approach with the evaluation of clinical probability, then order D-dimer if the PERC rule is positive, then adapt the D-dimer threshold for ordering chest imaging using clinical decision rules.
Collapse
Affiliation(s)
- Dorian Teissandier
- Department of Emergency, Pitié-Salpêtrière University Hospital, Paris, France
| | - Mélanie Roussel
- Department of Emergency, Centre Hospitalier Universitaire de Rouen, University of Rouen Normandy, Rouen, France
| | - Héloise Bannelier
- Department of Emergency, Pitié-Salpêtrière University Hospital, Paris, France
- UMRS 1166, IHU ICAN, Sorbonne University, Paris, France
| | - Yonathan Freund
- Department of Emergency, Pitié-Salpêtrière University Hospital, Paris, France
- UMRS 1166, IHU ICAN, Sorbonne University, Paris, France
| | - Pierre Catoire
- Department of Emergency, Pitié-Salpêtrière University Hospital, Paris, France
- UMRS 1166, IHU ICAN, Sorbonne University, Paris, France
| |
Collapse
|
4
|
Affiliation(s)
- Makoto Mo
- Department of Cardiovascular Surgery, Yokohama Minami Kyosai Hospital
| | - Yugo Yamashita
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| |
Collapse
|
5
|
Kovács A, Hantosi D, Szabó N, Letoha A, Lengyel C, Földesi I, Burián K, Palkó A, Veréb D, Kincses ZT. D-dimer levels to exclude pulmonary embolism and reduce the need for CT angiography in COVID-19 in an outpatient population. PLoS One 2024; 19:e0297023. [PMID: 38232069 DOI: 10.1371/journal.pone.0297023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 12/26/2023] [Indexed: 01/19/2024] Open
Abstract
OBJECTIVES Emerging results indicate that, in COVID-19, thromboembolic complications contribute to the high mortality and morbidity. Previous research showed that the prevalence of pulmonary embolism (PE) is between 25-50% in COVID-19 patients, however, most of these reports are based on data from patients with severe pneumonia, treated in intensive care units. MATERIALS AND METHODS We conducted a retrospective, single-center, observational study to estimate the prevalence of PE in COVID-19 patients who underwent CT angiography and to identify the most important predictors. Adult outpatients with COVID-19, who presented at our COVID Outpatient Clinic between 1st and 31st of March in 2021 and underwent CTA examination were included in this study. Multiple linear regression analysis was used to identify predictors of PE in COVID-19 patients. The predictors were: age, gender, disease duration, CT severity index and log-transformed quantitative D-dimer (logQDDIM) value. RESULTS 843 COVID-19 patients were included into the study. 82.56% (693 patients) of the infected patients had a pulmonary CTA examination and D-dimer levels (mean age: 59.82 years ± 15.66). 7.61% (53 patients) of the patients had PE. 2.02% (14 patients) of the patients had main branch or lobar PE. The multiple regression analysis found that only logQDDIM was a significant predictor. A logQDDIM cut-off value of 0.0169 (1.0171 ug/ml serum D-dimer) predicted PE with 99% sensitivity (p<0.0001, degree-of-freedom = 570, AUC = 0.72). CONCLUSIONS We demonstrated in a large cohort of COVID-19 patients that a cut-off value of QDDIM of 1ug/ml can exclude pulmonary embolism in an outpatient setting, implicating that QDDIM might potentially supersede CTA as a screening approach in COVID-19 outpatient clinics.
Collapse
Affiliation(s)
- Anita Kovács
- Department of Radiology, Albert Szent-Györgyi Medical Center, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Dóra Hantosi
- Department of Radiology, Albert Szent-Györgyi Medical Center, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Nikoletta Szabó
- Department of Neurology, Albert Szent-Györgyi Medical Center, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Annamária Letoha
- Department of Internal Medicine, Albert Szent-Györgyi Medical Center, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Csaba Lengyel
- Department of Internal Medicine, Albert Szent-Györgyi Medical Center, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Imre Földesi
- Department of Laboratory Medicine, Albert Szent-Györgyi Medical Center, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Katalin Burián
- Department of Medical Microbiology, Albert Szent-Györgyi Medical Center, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - András Palkó
- Department of Radiology, Albert Szent-Györgyi Medical Center, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Dániel Veréb
- Department of Radiology, Albert Szent-Györgyi Medical Center, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Zsigmond Tamás Kincses
- Department of Radiology, Albert Szent-Györgyi Medical Center, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| |
Collapse
|
6
|
Alagha Z, Bills E, Alastal M, Ghallab M, Al-Astal A, Mahdi A. The Harms of Unnecessary CT Pulmonary Angiography: A Case Report and Literature Review. J Investig Med High Impact Case Rep 2024; 12:23247096241258603. [PMID: 38840555 PMCID: PMC11155323 DOI: 10.1177/23247096241258603] [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: 03/17/2024] [Revised: 05/01/2024] [Accepted: 05/09/2024] [Indexed: 06/07/2024] Open
Abstract
Pulmonary embolism (PE) poses a significant health risk in the United States, with high mortality rates. Clinicians maintain a low threshold for suspecting PE, potentially leading to deviation from guideline-recommended algorithms and unnecessary computed tomography pulmonary angiography (CTPA). This case discusses a 46-year-old woman who presented with symptoms suggestive of PE following a prolonged road trip. Despite a low Wells score and negative D-dimer results, she underwent CTPA, resulting in an unnecessary and harmful interventional radiology-guided thrombectomy. This highlights the importance of adhering to guidelines in PE diagnosis to mitigate potential harms associated with the overuse of available medical tools.
Collapse
Affiliation(s)
| | - Ean Bills
- Marshall University, Huntington, WV, USA
| | | | | | | | | |
Collapse
|
7
|
Madsen SF, Christensen DM, Strange JE, Nouhravesh N, Kümler T, Gislason G, Lamberts M, Sindet‐Pedersen C. Short- and Long-Term Mortality for Patients With and Without a Cancer Diagnosis Following Pulmonary Embolism in Denmark, 2000 to 2020: A Nationwide Study. J Am Heart Assoc 2023; 12:e030191. [PMID: 38014671 PMCID: PMC10727333 DOI: 10.1161/jaha.123.030191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 10/19/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND New treatment regimens have been introduced in the past 20 years, which may influence the short- and long-term prognosis for patients with and without a cancer diagnosis following pulmonary embolism. However, newer studies investigating these trends are lacking. Therefore, we aimed to investigate the 30- and 31- to 365-day mortality following pulmonary embolism. METHODS AND RESULTS Using the Danish nationwide registries, patients with a diagnosis of pulmonary embolism between 2000 and 2020 were included. Age- and sex-standardized 30- and 31- to 365-day mortality was calculated and stratified by cancer status. In total, 60 614 patients (29.6% with recent cancer; mean age, 68.2 years) were included. The 30-day mortality for patients with no recent cancer decreased from 19.1% (95% CI, 17.9%-20.4%) in 2000 to 7.3% (95% CI, 6.7%-8.0%) in 2018 to 2020 (hazard ratio [HR], 0.36 [95% CI, 0.32-0.40]; P<0.001). The 30-day mortality for patients with recent cancer decreased from 32.2% (95% CI, 28.8%-36.6%) to 14.1% (95% CI, 12.7%-15.5%) (HR, 0.38 [95% CI, 0.33-0.44]; P<0.001). The 31- to 365-day mortality for patients with no recent cancer decreased from 12.5% (95% CI, 11.4%-13.6%) to 9.4% (95% CI, 8.6%-10.2%) (HR, 0.73 [95% CI, 0.64-0.83]; P<0.001).The 31- to 365-day mortality for patients with recent cancer remained stable: 39.4% (95% CI, 35.1%-43.7%) to 38.3% (95% CI, 35.9%-40.6%) (HR, 0.97 [95% CI, 0.84-1.12]; P=0.69). CONCLUSIONS From 2000 to 2020, improvements were observed in 30-day mortality following pulmonary embolism regardless of cancer status. For patients with recent cancer, 31- to 365-day mortality did not improve, whereas a minor improvement was observed for patients without recent cancer.
Collapse
Affiliation(s)
- Sophie Fredslund Madsen
- Department of Cardiology, Herlev and Gentofte HospitalUniversity of CopenhagenHellerupDenmark
| | | | - Jarl Emanuel Strange
- Department of Clinical Medicine, Faculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark
- Department of Cardiology, The Heart CenterCopenhagen University Hospital RigshospitaletCopenhagenDenmark
| | - Nina Nouhravesh
- Department of Clinical Medicine, Faculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark
| | - Thomas Kümler
- Department of Clinical Medicine, Faculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark
| | - Gunnar Gislason
- Department of Cardiology, Herlev and Gentofte HospitalUniversity of CopenhagenHellerupDenmark
- Danish Heart FoundationCopenhagenDenmark
- Department of Clinical Medicine, Faculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark
| | - Morten Lamberts
- Department of Cardiology, Herlev and Gentofte HospitalUniversity of CopenhagenHellerupDenmark
- Department of Clinical Medicine, Faculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark
| | - Caroline Sindet‐Pedersen
- Danish Heart FoundationCopenhagenDenmark
- Department of Clinical Medicine, Faculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark
| |
Collapse
|
8
|
Thériault G. Réfutation des mythes entourant le dépistage. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2023; 69:e216-e220. [PMID: 37963800 PMCID: PMC10645457 DOI: 10.46747/cfp.6911e216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Affiliation(s)
- Guylène Thériault
- Directrice du volet Rôle du médecin et directrice du Centre de pédagogie au Campus Outaouais de la Faculté de médecine de l’Université McGill à Montréal (Québec)
| |
Collapse
|
9
|
Thériault G. Debunking myths about screening: How to screen more judiciously. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2023; 69:767-771. [PMID: 37963786 PMCID: PMC10645442 DOI: 10.46747/cfp.6911767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Affiliation(s)
- Guylène Thériault
- Academic Lead for the Physicianship Component and Director of Pedagogy at the Outaouais Medical Campus in the Faculty of Medicine at McGill University in Montréal, Que
| |
Collapse
|
10
|
Falster C, Hellfritzsch M, Gaist TA, Brabrand M, Bhatnagar R, Nybo M, Andersen NH, Egholm G. Comparison of international guideline recommendations for the diagnosis of pulmonary embolism. Lancet Haematol 2023; 10:e922-e935. [PMID: 37804848 DOI: 10.1016/s2352-3026(23)00181-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 06/09/2023] [Accepted: 06/16/2023] [Indexed: 10/09/2023]
Abstract
Pulmonary embolism is one of the leading causes of death due to cardiovascular disease. Timely diagnosis is crucial, but challenging, as the clinical presentation of pulmonary embolism is unspecific and easily mistaken for other common medical emergencies. Clinical prediction rules and D-dimer measurement allow stratification of patients into groups of expected prevalence and are key elements in adequate selection of patients for diagnostic imaging; however, the strengths and weaknesses of the multiple proposed prediction rules, when to measure D-dimer, and which cutoff to apply might be elusive to a significant proportion of physicians. 13 international guidelines authored by medical societies or expert author groups provide recommendations on facets of the diagnostic investigations in suspected pulmonary embolism, some of which are hallmarked by pronounced heterogeneity. This Review summarises key recommendations of each guideline, considers the most recent evidence on the topic, compares guideline recommendations on each facet of the diagnosis of pulmonary embolism, and provides a synthesis on the most common recommendations.
Collapse
Affiliation(s)
- Casper Falster
- Odense Respiratory Research Unit, University of Southern Denmark, Odense, Denmark; Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark.
| | - Maja Hellfritzsch
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Danish Society of Thrombosis and Hemostasis, Roskilde, Denmark
| | | | - Mikkel Brabrand
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark; Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Rahul Bhatnagar
- Respiratory Medicine Department, North Bristol National Health Service Trust, Southmead Hospital, Bristol, UK; Academic Respiratory Unit, University of Bristol, Bristol, UK
| | - Mads Nybo
- Department of Clinical Biochemistry, Odense University Hospital, Odense, Denmark
| | | | - Gro Egholm
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| |
Collapse
|
11
|
Sullivan RD, Shults NV, Suzuki YJ. Case Report: Two Case Reports of Pulmonary Hypertension after mRNA COVID-19 Vaccination. Diseases 2023; 11:114. [PMID: 37754310 PMCID: PMC10528902 DOI: 10.3390/diseases11030114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 08/24/2023] [Accepted: 09/01/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND We herein report two cases of sudden onset symptomatic pulmonary hypertension after coronavirus disease 2019 (COVID-19) vaccination. CASE SUMMARY Pulmonary hypertension in previously healthy adult males occurred within three weeks of receiving the second dose of the Pfizer (BNT162b2) mRNA COVID-19 vaccine from different lots. Both patients experienced a sudden onset of severe fatigue and dyspnea on exertion with negative severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction (PCR) testing. The diagnosis was made by serial transthoracic echocardiography in the first case and by both transthoracic echocardiography and right heart catheterization in the second. Both cases resulted in functional limitations and likely permanent organ damage. No evidence of pulmonary emboli was detected in either case. DISCUSSION Pulmonary hypertension is a serious disease characterized by damage to lung vasculature and restricted blood flow through narrowed arteries from the right to left heart. The onset of symptoms is typically insidious, progressive and incurable, leading to right heart failure and premature death. The World Health Organization (WHO) classifies pulmonary hypertension into five categories and recently re-defined it as a resting mean pulmonary artery pressure greater than 20 mmHg. Sudden onset pulmonary hypertension would only be expected in the settings of surgical pneumonectomy or massive pulmonary emboli with compromise of at least 50% of the lung vasculature. We present here two novel cases of sudden onset pulmonary hypertension without evidence of pulmonary emboli, both of which occurred after receiving a COVID-19 mRNA vaccine.
Collapse
Affiliation(s)
| | - Nataliia V. Shults
- Department of Biology, Georgetown University, Washington, DC 20007, USA;
| | - Yuichiro J. Suzuki
- Department of Pharmacology and Physiology, Georgetown University Medical Center, Washington, DC 20007, USA
| |
Collapse
|
12
|
Roussel M, Bloom B, Taalba M, Choquet C, Douillet D, Fémy F, Marouk A, Gorlicki J, Gerlier C, Macrez R, Arnaud E, Bompard R, Montassier E, Hugli O, Czopik C, Eyer X, Benhamed A, Peyrony O, Chouihed T, Penaloza A, Marra A, Laribi S, Reuter PG, Behringer W, Douplat M, Guenezan J, Javaud N, Lucidarme O, Cachanado M, Aparicio-Monforte A, Freund Y. Temporal Trends in the Use of Computed Tomographic Pulmonary Angiography for Suspected Pulmonary Embolism in the Emergency Department : A Retrospective Analysis. Ann Intern Med 2023. [PMID: 37216659 DOI: 10.7326/m22-3116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND Recently, validated clinical decision rules have been developed that avoid unnecessary use of computed tomographic pulmonary angiography (CTPA) in patients with suspected pulmonary embolism (PE) in the emergency department (ED). OBJECTIVE To measure any resulting change in CTPA use for suspected PE. DESIGN Retrospective analysis. SETTING 26 European EDs in 6 countries. PATIENTS Patients with CTPA performed for suspected PE in the ED during the first 7 days of each odd month between January 2015 and December 2019. MEASUREMENTS The primary end points were the CTPAs done for suspected PE in the ED and the number of PEs diagnosed in the ED each year adjusted to an annual census of 100 000 ED visits. Temporal trends were estimated using generalized linear mixed regression models. RESULTS 8970 CTPAs were included (median age, 63 years; 56% female). Statistically significant temporal trends for more frequent use of CTPA (836 per 100 000 ED visits in 2015 vs. 1112 in 2019; P < 0.001), more diagnosed PEs (138 per 100 000 in 2015 vs. 164 in 2019; P = 0.028), a higher proportion of low-risk PEs (annual percent change [APC], 13.8% [95% CI, 2.6% to 30.1%]) with more ambulatory management (APC, 19.3% [CI, 4.1% to 45.1%]), and a lower proportion of intensive care unit admissions (APC, -8.9% [CI, -17.1% to -0.3%]) were observed. LIMITATION Data were limited to 7 days every 2 months. CONCLUSION Despite the recent validation of clinical decision rules to limit the use of CTPA, an increase in the CTPA rate along with more diagnosed PEs and especially low-risk PEs were instead observed. PRIMARY FUNDING SOURCE None specific for this study.
Collapse
Affiliation(s)
- Melanie Roussel
- Sorbonne Université, UMR Inserm 1166, IHU ICAN, Paris; Emergency Department, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France (M.R., Y.F.)
| | - Ben Bloom
- Emergency Department, Royal London Hospital, London, United Kingdom (B.B.)
| | - Mehdi Taalba
- Emergency Department, Rouen University Hospital, Rouen, France (M.T.)
| | - Christophe Choquet
- Emergency Department, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France (C. Choquet)
| | - Delphine Douillet
- Department of Emergency Medicine, University Hospital of Angers, Angers; and UNIV Angers, UMR MitoVasc CNRS 6215 INSERM 1083, Angers, France (D.D.)
| | - Florent Fémy
- Emergency Department, Hôpital Européen Georges-Pompidou, Assistance Publique-Hôpitaux de Paris, Université Paris Cite, Paris; and Toxicology and Chemical Risks Department, French Armed Forces Biomedical Institute, Brétigny-sur-Orge, France (F.F.)
| | - Alexis Marouk
- Emergency Department, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France (A. Marouk)
| | - Judith Gorlicki
- Emergency Department, Hôpital Avicenne, Assistance Publique-Hôpitaux de Paris, Bobigny, France (J. Golicki)
| | - Camille Gerlier
- Emergency Department, Hôpital Saint-Joseph, Paris, France (C.G.)
| | - Richard Macrez
- Emergency Department, CHU Caen Côte de Nacre, Normandie Université UNICAEN, INSERM PhIND Institut Blood and Brain, Caen, France (R.M.)
| | - Emilien Arnaud
- Department of Emergency Medicine, Amiens-Picardy University Hospital, Amiens, France (E.A.)
| | - Rudy Bompard
- Emergency Department, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, Paris, France (R.B.)
| | | | - Olivier Hugli
- Emergency Department, Lausanne University Hospital Emergency Care Service, Lausanne, Switzerland (O.H.)
| | - Charlotte Czopik
- Emergency Department, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France (C. Czopik)
| | - Xavier Eyer
- Emergency Department, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Paris, France (X.E.)
| | - Axel Benhamed
- Emergency Department, Hospices Civils de Lyon, Lyon, France (A.B., M.D.)
| | - Olivier Peyrony
- Emergency Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Paris, France (O.P.)
| | - Tahar Chouihed
- Emergency Department, University Hospital of Nancy, Nancy, France (T.C.)
| | - Andrea Penaloza
- Emergency Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium (A.P.)
| | - Alessio Marra
- Emergency Department, ASST Papa Giovanni XXIII, Bergamo, Italy (A. Marra)
| | - Said Laribi
- Tours University, Emergency Medicine Department, Tours University Hospital, Tours, France (S.L.)
| | - Paul-Georges Reuter
- Emergency Department, Hôpital Ambroise Paré, Assistance Publique-Hôpitaux de Paris, Boulogne; and Université Versailles-Saint Quentin en Yvelines, Boulogne, France (P.-G.R.)
| | - Wilhelm Behringer
- Department of Emergency Medicine, Medical University Vienna, Vienna General Hospital, Vienna, Austria (W.B.)
| | - Marion Douplat
- Emergency Department, Hospices Civils de Lyon, Lyon, France (A.B., M.D.)
| | - Jeremy Guenezan
- Emergency Department, University Hospital of Poitiers, Poitiers, France (J. Guenezen)
| | - Nicolas Javaud
- Emergency Department, Hôpital Louis-Mourier, Assistance Publique-Hôpitaux de Paris, Colombes; and Reference Center for Bradykinin Angiodema (CReAk), Université Paris Cite, Colombes, France (N.J.)
| | - Olivier Lucidarme
- Sorbonne Université, UMR Inserm 1166, IHU ICAN, Paris; and Sorbonne Université, CNRS, INSERM, Laboratoire d'Imagerie Biomédicale LIB, Paris, France (O.L.)
| | - Marine Cachanado
- Department of Clinical Pharmacology and Clinical Research Platform Paris-East (URCEST-CRC-CRB), Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France (M.C., A.A.)
| | - Ainhoa Aparicio-Monforte
- Department of Clinical Pharmacology and Clinical Research Platform Paris-East (URCEST-CRC-CRB), Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France (M.C., A.A.)
| | - Yonathan Freund
- Sorbonne Université, UMR Inserm 1166, IHU ICAN, Paris; Emergency Department, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France (M.R., Y.F.)
| |
Collapse
|
13
|
Kharawala A, Seo J, Barzallo D, Romero GH, Demirhan YE, Duarte GJ, Vegivinti CTR, Hache-Marliere M, Balasubramanian P, Santos HT, Nagraj S, Alhuarrat MAD, Karamanis D, Varrias D, Palaiodimos L. Assessment of the Utilization of Validated Diagnostic Predictive Tools and D-Dimer in the Evaluation of Pulmonary Embolism: A Single-Center Retrospective Cohort Study from a Public Hospital in New York City. J Clin Med 2023; 12:jcm12113629. [PMID: 37297824 DOI: 10.3390/jcm12113629] [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: 04/03/2023] [Revised: 05/17/2023] [Accepted: 05/18/2023] [Indexed: 06/12/2023] Open
Abstract
INTRODUCTION A significant increase in the use of computed tomography with pulmonary angiography (CTPA) for the diagnosis of pulmonary embolism (PE) has been observed in the past twenty years. We aimed to investigate whether the validated diagnostic predictive tools and D-dimers were adequately utilized in a large public hospital in New York City. METHODS We conducted a retrospective review of patients who underwent CTPA for the specific indication of ruling out PE over a period of one year. Two independent reviewers, blinded to each other and to the CTPA and D-dimer results, estimated the clinical probability (CP) of PE using Well's score, the YEARS algorithm, and the revised Geneva score. Patients were classified based on the presence or absence of PE in the CTPA. RESULTS A total of 917 patients were included in the analysis (median age: 57 years, female: 59%). The clinical probability of PE was considered low by both independent reviewers in 563 (61.4%), 487 (55%), and 184 (20.1%) patients based on Well's score, the YEARS algorithm, and the revised Geneva score, respectively. D-dimer testing was conducted in less than half of the patients who were deemed to have low CP for PE by both independent reviewers. Using a D-dimer cut-off of <500 ng/mL or the age-adjusted cut-off in patients with a low CP of PE would have missed only a small number of mainly subsegmental PE. All three tools, when combined with D-dimer < 500 ng/mL or <age-adjusted cut-off, yielded a NPV of > 95%. CONCLUSION All three validated diagnostic predictive tools were found to have significant diagnostic value in ruling out PE when combined with a D-dimer cut-off of <500 ng/mL or the age-adjusted cut-off. Excessive use of CTPA was likely secondary to suboptimal use of diagnostic predictive tools.
Collapse
Affiliation(s)
- Amrin Kharawala
- Department of Medicine, New York City Health + Hospitals/Jacobi, Bronx, NY 10461, USA
- Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Jiyoung Seo
- Department of Medicine, New York City Health + Hospitals/Jacobi, Bronx, NY 10461, USA
- Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Diego Barzallo
- Department of Medicine, New York City Health + Hospitals/Jacobi, Bronx, NY 10461, USA
- Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Gabriel Hernandez Romero
- Department of Medicine, New York City Health + Hospitals/Jacobi, Bronx, NY 10461, USA
- Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Yunus Emre Demirhan
- Department of Medicine, New York City Health + Hospitals/Jacobi, Bronx, NY 10461, USA
- Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Gustavo J Duarte
- Department of Medicine, New York City Health + Hospitals/Jacobi, Bronx, NY 10461, USA
- Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Charan Thej Reddy Vegivinti
- Department of Medicine, New York City Health + Hospitals/Jacobi, Bronx, NY 10461, USA
- Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Manuel Hache-Marliere
- Department of Medicine, New York City Health + Hospitals/Jacobi, Bronx, NY 10461, USA
- Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Prasanth Balasubramanian
- Department of Medicine, New York City Health + Hospitals/Jacobi, Bronx, NY 10461, USA
- Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Heitor Tavares Santos
- Department of Medicine, New York City Health + Hospitals/Jacobi, Bronx, NY 10461, USA
- Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Sanjana Nagraj
- Department of Medicine, New York City Health + Hospitals/Jacobi, Bronx, NY 10461, USA
- Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Majd Al Deen Alhuarrat
- Department of Medicine, New York City Health + Hospitals/Jacobi, Bronx, NY 10461, USA
- Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Dimitrios Karamanis
- Department of Economics, University of Piraeus, 18534 Attica, Greece
- Department of Health Informatics, Rutgers School of Health Professions, Newark, NJ 07107, USA
| | - Dimitrios Varrias
- Department of Medicine, New York City Health + Hospitals/Jacobi, Bronx, NY 10461, USA
- Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Leonidas Palaiodimos
- Department of Medicine, New York City Health + Hospitals/Jacobi, Bronx, NY 10461, USA
- Albert Einstein College of Medicine, Bronx, NY 10461, USA
- School of Medicine, City University of New York, New York, NY 10031, USA
| |
Collapse
|
14
|
Luijten D, Klok FA, van Mens TE, Huisman MV. Clinical controversies in the management of acute pulmonary embolism: evaluation of four important but controversial aspects of acute pulmonary embolism management that are still subject of debate and research. Expert Rev Respir Med 2023; 17:181-189. [PMID: 36912598 DOI: 10.1080/17476348.2023.2190888] [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: 12/19/2022] [Accepted: 03/10/2023] [Indexed: 03/14/2023]
Abstract
INTRODUCTION Acute pulmonary embolism (PE) is a disease with a broad spectrum of clinical presentations. While some patients can be treated at home or may even be left untreated, other patients require an aggressive approach with reperfusion treatment. AREAS COVERED (1) Advanced reperfusion treatment in hemodynamically stable acute PE patients considered to be at high risk of decompensation and death, (2) the treatment of subsegmental pulmonary embolism, (3) outpatient treatment for hemodynamically stable PE patients with signs of right ventricle (RV) dysfunction, and (4) the optimal approach to identify and treatpost-PE syndrome. EXPERT OPINION Outside clinical trials, hemodynamically stable acute PE patients should not be treated with primary reperfusion therapy. Thrombolysis and/or catheter-directed therapy are only to be considered as rescue treatment. Subsegmental PE can be left untreated in selected low-risk patients, after proximal deep vein thrombosis has been ruled out. Patients with an sPESI or Hestia score of 0 criteria can be treated at home, independent of the presence of RV overload. Finally, health-care providers should be aware of post-PE syndrome and diagnose chronic thromboembolic pulmonary disease (CTEPD) as early as possible. Persistently symptomatic patients without CTEPD benefit from exercise training and cardiopulmonary rehabilitation.
Collapse
Affiliation(s)
- Dieuwke Luijten
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands
| | - Thijs E van Mens
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam Reproduction and Development, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Menno V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands
| |
Collapse
|
15
|
Jha S. Making Radiology Antifragile. J Am Coll Radiol 2023; 20:470-472. [PMID: 36805491 PMCID: PMC9969334 DOI: 10.1016/j.jacr.2023.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 02/15/2023] [Indexed: 02/19/2023]
Affiliation(s)
- Saurabh Jha
- Associate Professor of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania.
| |
Collapse
|
16
|
Thériault G, Grad R, Dickinson JA, Singh H, Antao V, Bell NR, Szafran O. Gare aux torts causés par les surdiagnostics engendrés par le dépistage, l’abaissement des seuils de diagnostic et par la découverte d’incidentalomes. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2023; 69:e33-e37. [PMID: 36813513 PMCID: PMC9945899 DOI: 10.46747/cfp.6902e33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Affiliation(s)
- Guylène Thériault
- Directrice du volet Rôle du médecin et directrice de la Pédagogie au Campus Outaouais de la Faculté de médecine de l'Université McGill à Montréal (Québec).
| | - Roland Grad
- Professeur agrégé au Département de médecine familiale de l'Université McGill
| | - James A Dickinson
- Professeur au Département de médecine familiale et au Département des sciences de la santé communautaire à l'Université de Calgary (Alberta)
| | - Harminder Singh
- Professeur agrégé au Département de médecine interne et au Département des sciences de santé communautaire à l'Université du Manitoba à Winnipeg et au Département d'hématologie et d'oncologie médicale à ActionCancer Manitoba
| | - Viola Antao
- Professeure agrégée au Département de médecine familiale et communautaire de l'Université de Toronto (Ontario)
| | - Neil R Bell
- Professeur au Département de médecine familiale de l'Université de l'Alberta à Edmonton
| | - Olga Szafran
- Directrice associée de la recherche au Département de médecine familiale de l'Université de l'Alberta
| |
Collapse
|
17
|
Maskell G. Incidental findings in medical imaging. Br J Radiol 2023; 96:20211352. [PMID: 35119912 PMCID: PMC9975528 DOI: 10.1259/bjr.20211352] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 01/13/2022] [Accepted: 01/14/2022] [Indexed: 01/27/2023] Open
Abstract
The success of medical imaging as a diagnostic tool has resulted in a continuing increase in its use. Technological advances mean that images are now acquired at higher resolution and in greater volumes than ever before. This has led to an increase in the detection of findings which do not appear to be related to the primary purpose of the examination and have been termed "incidental". Many of these will be harmless but some will carry significant implications for the patient's health. Determining which of these findings are significant and which may be safely disregarded is an increasing problem in radiology practice. Radiologists should familiarise themselves with the more common incidental findings in order to make the best possible estimation of their importance in each case and to allow them to make appropriate recommendations for further investigation where this is indicated. The decision to advise further investigation carries implications for the patient and the service as a whole and requires careful consideration.
Collapse
Affiliation(s)
- Giles Maskell
- Department of Clinical Imaging, Royal Cornwall Hospital, Truro, UK
| |
Collapse
|
18
|
Thériault G, Grad R, Dickinson JA, Singh H, Antao V, Bell NR, Szafran O. Beware of overdiagnosis harms from screening, lower diagnostic thresholds, and incidentalomas. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2023; 69:97-100. [PMID: 36813526 PMCID: PMC9945906 DOI: 10.46747/cfp.690297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Affiliation(s)
- Guylène Thériault
- Academic Lead for the Physicianship Component and the Director of Pedagogy at Outaouais Medical Campus in the Faculty of Medicine at McGill University in Montréal, Que.
| | - Roland Grad
- Associate Professor in the Department of Family Medicine at McGill University
| | - James A Dickinson
- Professor in the Department of Family Medicine and the Department of Community Health Sciences at the University of Calgary in Alberta
| | - Harminder Singh
- Associate Professor in the Department of Internal Medicine and the Department of Community Health Sciences at the University of Manitoba in Winnipeg and in the Department of Hematology and Oncology for CancerCare Manitoba
| | - Viola Antao
- Associate Professor in the Department of Family and Community Medicine at the University of Toronto in Ontario
| | - Neil R Bell
- Professor in the Department of Family Medicine at the University of Alberta in Edmonton
| | - Olga Szafran
- Associate Director of Research in the Department of Family Medicine at the University of Alberta
| |
Collapse
|
19
|
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.
Collapse
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
| |
Collapse
|
20
|
Baumgartner C. [From Asymptomatic to Fatal: Pulmonary Embolism Remains a Diagnostic and Therapeutic Challenge]. PRAXIS 2022; 111:903-904. [PMID: 36475362 DOI: 10.1024/1661-8157/a003962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Affiliation(s)
- Christine Baumgartner
- Universitätsklinik für Allgemeine Innere Medizin, Inselspital, Universitätsspital Bern, Bern, Schweiz
| |
Collapse
|
21
|
Abstract
IMPORTANCE Pulmonary embolism (PE) is characterized by occlusion of blood flow in a pulmonary artery, typically due to a thrombus that travels from a vein in a lower limb. The incidence of PE is approximately 60 to 120 per 100 000 people per year. Approximately 60 000 to 100 000 patients die from PE each year in the US. OBSERVATIONS PE should be considered in patients presenting with acute chest pain, shortness of breath, or syncope. The diagnosis is determined by chest imaging. In patients with a systolic blood pressure of at least 90 mm Hg, the following 3 steps can be used to evaluate a patient with possible PE: assessment of the clinical probability of PE, D-dimer testing if indicated, and chest imaging if indicated. The clinical probability of PE can be assessed using a structured score or using clinical gestalt. In patients with a probability of PE that is less than 15%, the presence of 8 clinical characteristics (age <50 years, heart rate <100/min, an oxygen saturation level of > 94%, no recent surgery or trauma, no prior venous thromboembolism event, no hemoptysis, no unilateral leg swelling, and no estrogen use) identifies patients at very low risk of PE in whom no further testing is needed. In patients with low or intermediate clinical probability, a D-dimer level of less than 500 ng/mL is associated with a posttest probability of PE less than 1.85%. In these patients, PE can be excluded without chest imaging. A further refinement of D-dimer threshold is possible in patients aged 50 years and older, and in patients with a low likelihood of PE. Patients with a high probability of PE (ie, >40% probability) should undergo chest imaging, and D-dimer testing is not necessary. In patients with PE and a systolic blood pressure of 90 mm Hg or higher, compared with heparin combined with a vitamin K antagonist such as warfarin followed by warfarin alone, direct oral anticoagulants such as apixaban, edoxaban, rivaroxaban, or dabigatran, are noninferior for treating PE and have a 0.6% lower rate of bleeding. In patients with PE and systolic blood pressure lower than 90 mm Hg, systemic thrombolysis is recommended and is associated with an 1.6% absolute reduction of mortality (from 3.9% to 2.3%). CONCLUSIONS AND RELEVANCE In the US, PE affects approximately 370 000 patients per year and may cause approximately 60 000 to 100 000 deaths per year. First-line therapy consists of direct oral anticoagulants such as apixaban, edoxaban, rivaroxaban, or dabigatran, with thrombolysis reserved for patients with systolic blood pressure lower than 90 mm Hg.
Collapse
Affiliation(s)
- Yonathan Freund
- Sorbonne Université, Improving Emergency Care FHU, Paris, France
- Emergency Department, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Fleur Cohen-Aubart
- Sorbonne Université, Improving Emergency Care FHU, Paris, France
- Internal Medicine Department 2, French National Referral Center for Rare Systemic Diseases and Histiocytoses, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Ben Bloom
- Emergency Department, Barts Health NHS Trust, London, United Kingdom
| |
Collapse
|
22
|
Bannelier H, Gorlicki J, Penaloza A, Douillet D, Roy PM, Freund Y, Roussel M. Evaluation of the "hemoptysis" item in clinical decision rules for the diagnosis of pulmonary embolism in the emergency department. Acad Emerg Med 2022; 29:1205-1212. [PMID: 35975482 DOI: 10.1111/acem.14574] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 05/31/2022] [Accepted: 07/12/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Hemoptysis is not common in pulmonary embolism (PE) and lacks specificity for its diagnosis. However, this item is present in different validated scores that estimate the clinical probability of PE. The relevance of this item in clinical decision rules (CDRs) is not clearly established. OBJECTIVE The aim of this study was to evaluate the impact of removing the "hemoptysis" item from the PERC, YEARS, and PEGeD CDR in patients with low clinical probability of PE. DESIGN This was a post hoc analysis of two European prospective cohorts, which included 2968 patients presenting to the ED with a low clinical probability of PE (PROPER and PERCEPIC) and a 3-month follow-up. The primary endpoint was the false-negative rate of a CDR score without the hemoptysis item. Secondary endpoints included the potential reduction of chest imaging if the item hemoptysis was to be removed and risk stratification of the Geneva and Wells scores without the hemoptysis item. RESULTS Of 2968 patients included (mean ± SD age 46 ± 18 years, 53% female), 87 patients (3%) had a PE diagnosed at 3 months. A total of 2908 were followed-up at 3 months and analyzed. Using the PERC rule with and without the hemoptysis item, there were 13 and 14 missed cases of PE, respectively (failure rate 0.45% [95% CI 0.25%-0.78%] and 0.48% [95% CI 0.27%-0.82%]). Using the YEARS strategy, there were 11 missed PE cases with or without the hemoptysis item (false-negative rate 0.57% [95% CI 0.30%-1.05%]). With the PERC and YEARS rule, removing the hemoptysis item would have led to a 1% reduction in chest imaging. The PEGeD strategy was not modified by the removal of the hemoptysis item. CONCLUSIONS The hemoptysis item could be safely removed from the PERC, YEARS, and PEGeD CDRs. However, there was no subsequent clinically relevant reduction of chest imaging.
Collapse
Affiliation(s)
- Héloïse Bannelier
- Emergency Department, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Judith Gorlicki
- Emergency Department, Hôpital Avicenne, Assistance Publique-Hôpitaux de Paris, INSERM U942-MASCOT, Bobigny, France
| | - Andrea Penaloza
- Emergency Department, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Bruxelles, Belgium
| | - Delphine Douillet
- Emergency Department, Angers University Hospital, Angers, France.,FCRIN, INNOVTE, Saint Etienne, France
| | - Pierre-Marie Roy
- Emergency Department, Angers University Hospital, Angers, France.,FCRIN, INNOVTE, Saint Etienne, France
| | - Yonathan Freund
- Emergency Department, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France.,Sorbonne Université, Improving Emergency Care FHU, Paris, France
| | - Melanie Roussel
- Emergency Department, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France.,Sorbonne Université, Improving Emergency Care FHU, Paris, France
| |
Collapse
|
23
|
Comparison of the safety and efficacy of YEARS, PEGeD, 4PEPS or the sole item "PE is the most likely diagnosis" strategies for the diagnosis of pulmonary embolism in the emergency department: post-hoc analysis of two European cohort studies. Eur J Emerg Med 2022; 29:341-347. [PMID: 36062433 DOI: 10.1097/mej.0000000000000967] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND The optimal strategy for the diagnosis of pulmonary embolism (PE) in the emergency department (ED) remains debated. To reduce the need of imaging testing, several rules have been recently validated using an elevated D-dimer threshold. OBJECTIVE To validate the safety of different diagnostic strategies and compare the efficacy in terms of chest imaging testing. DESIGN AND PATIENTS Post-hoc analysis of individual data of 3330 adult patients without a high clinical probability of PE in the ED followed-up at 3 months in France and Spain (1916 from the PROPER cohort, 1414 from the MODIGLIANI cohort). EXPOSURE Four diagnostic strategies with an elevated D-dimer threshold if PE is unlikely. The YEARS combined with Pulmonary Embolism Rule-out Criteria (PERC) the pulmonary embolism graduated D-dimer (PEGeD) combined with PERC and the 4-level pulmonary embolism probability score (4PEPS) rules were assessed. A modified simplified (MODS) rule with a simplified YEARS reduced to the sole item of "Is PE the most likely diagnosis" combined with PERC was also tested. OUTCOME MEASURE AND ANALYSIS The primary outcome was the proportion of diagnosed PE or deep venous thrombosis at 3 months in patients in whom PE could have been excluded without chest imaging according to the tested strategy. The safety of a strategy was confirmed if the failure rate was less than 1.85%. The secondary outcome was the use of imaging testing according to each rule. RESULTS Among 3330 analyzed patients, 150 (4.5%) had a PE. The number of missed PEs were 25, 29, 30 and 26 for the PERC+YEARS, PERC+PEGeD, 4PEPS and MODS rules respectively, with a failure rate of 0.75% (95% CI 0.51% to 1.10%), 0.87% (0.61% to 1.25%), 0.90% (0.63% to 1.28%) and 0.78% (0.53% to 1.14%) respectively. There was no significant difference in the failure rate between rules. Except for a significant lower use of chest imaging for 4PEPS compared to YEARS (14.9% vs 16.3%, difference -1.4% [95%CI -2.1% to -0.8%]), there was no difference in the proportion of imaging testing. CONCLUSION In this post-hoc analysis of patients with suspicion of PE, YEARS and PEGeD combined with PERC, and 4PEPS were safe to exclude PE. The safety of the modified simplified MODS strategy was also confirmed. There was no significant difference of the failure rate between strategies.
Collapse
|
24
|
Safai Zadeh E, Dietrich CF, Kmoth L, Trenker C, Alhyari A, Ludwig M, Görg C. Peripheral Pulmonary Lesions in Confirmed Pulmonary Arterial Embolism: Follow-up Study of B-Mode Ultrasound and of Perfusion Patterns Using Contrast-Enhanced Ultrasound (CEUS). JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2022; 41:1713-1721. [PMID: 34694040 DOI: 10.1002/jum.15852] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 09/20/2021] [Accepted: 09/22/2021] [Indexed: 05/18/2023]
Abstract
PURPOSE This retrospective study aimed to describe the B-mode lung ultrasound (B-LUS) and contrast-enhanced ultrasound (CEUS) follow-up patterns of peripheral pulmonary lesions (PPLs) in patients with confirmed pulmonary embolism (PE). PATIENTS AND METHODS Data from 27 patients with a confirmed diagnosis of PE and PPLs over 5 mm from October 2009 to November 2018 were included retrospectively in the study. The inclusion criteria were performance of a baseline CEUS examination, a short-term B-LUS and CEUS follow-up, and a long-term B-LUS follow-up of PPLs. The homogeneity of enhancement of PPLs (homogeneous/inhomogeneous/absent) on CEUS and the presence and size of PPLs on B-LUS were evaluated. RESULTS A total of n = 25/27 (92.6%) lesions showed absent or inhomogeneous enhancement during baseline examination or short-term follow-up, indicating impaired perfusion. On short-term CEUS follow-up, 9/27 cases (33.3%) showed a pattern shift. On B-LUS long-term follow-up, 26/27 lesions (96.3%) were detectable for an average of 10 weeks (range 3-32 weeks). The size of reference lesions was significantly reduced at the time of the final follow-up examination (P < .05). CONCLUSION B-LUS follow-up showed that, in patients with confirmed PE, PPLs had a delayed regression. On CEUS follow-up examination, various perfusion patterns of PPLs were observed, indicating the different ages and the variable reparative processes of pulmonary infarction. In PPLs independent of the underlying signs and symptoms, follow-up B-LUS and CEUS examinations may be helpful for a possible retrospective diagnosis of peripheral pulmonary infarction suggestive of PE.
Collapse
Affiliation(s)
- Ehsan Safai Zadeh
- Interdisciplinary Center of Ultrasound Diagnostics, University Hospital Giessen and Marburg, Philipps University of Marburg, Marburg, Germany
| | - Christoph Frank Dietrich
- Department Allgemeine Innere Medizin (DAIM), Kliniken Hirslanden Bern, Beau Site, Salem und Permanence, Bern, Switzerland
| | - Laila Kmoth
- Interdisciplinary Center of Ultrasound Diagnostics, University Hospital Giessen and Marburg, Philipps University of Marburg, Marburg, Germany
| | - Corinna Trenker
- Haematology, Oncology and Immunology, University Hospital Giessen and Marburg, Philipps University of Marburg, Marburg, Germany
| | - Amjad Alhyari
- Gastroenterology, Endocrinology, Metabolism and Clinical Infectiology, University Hospital Giessen and Marburg, Philipps University of Marburg, Marburg, Germany
| | - Michael Ludwig
- Clinic for Internal Medicine, Bundeswehrkrankenhaus Berlin, Berlin, Germany
| | - Christian Görg
- Interdisciplinary Center of Ultrasound Diagnostics, University Hospital Giessen and Marburg, Philipps University of Marburg, Marburg, Germany
- Gastroenterology, Endocrinology, Metabolism and Clinical Infectiology, University Hospital Giessen and Marburg, Philipps University of Marburg, Marburg, Germany
| |
Collapse
|
25
|
Kauppi JM, Airaksinen KEJ, Saha J, Bondfolk A, Pouru JP, Purola P, Jaakkola S, Lehtonen J, Vasankari T, Juonala M, Kiviniemi T. Adherence to risk-assessment protocols to guide computed tomography pulmonary angiography in patients with suspected pulmonary embolism. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2022; 8:461-468. [PMID: 33725123 PMCID: PMC9170567 DOI: 10.1093/ehjqcco/qcab020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 03/05/2021] [Accepted: 03/16/2021] [Indexed: 12/28/2022]
Abstract
AIMS The use of computed tomography pulmonary angiography (CTPA) in the detection of pulmonary embolism (PE) has considerably increased due developing technology and better availability of imaging. The underuse of pre-test probability scores and overuse of CTPA has been previously reported. We sought to investigate the indications for CTPA at a University Hospital emergency clinic and seek for factors eliciting the potential overuse of CTPA. METHODS AND RESULTS Altogether 1001 patients were retrospectively collected and analysed from the medical records using a structured case report form. PE was diagnosed in 222/1001 (22.2%) of patients. Patients with PE had more often prior PE/deep vein thrombosis, bleeding/thrombotic diathesis and less often asthma, chronic obstructive pulmonary disease, coronary artery disease, or decompensated heart failure. Patients were divided into three groups based on Wells PE risk-stratification score and two groups based on the revised Geneva score. A total of 9/382 (2.4%), 166/527 (31.5%), and 47/92 (52.2%) patients had PE in the CTPA in the low, intermediate, and high pre-test likelihood groups according to Wells score, and 200/955 (20.9%) and 22/46 (47.8%) patients had PE in the CTPA in the low-intermediate and the high pre-test likelihood groups according to the revised Geneva score, respectively. D-dimer was only measured from 568/909 (62.5%) and 597/955 (62.5%) patients who were either in the low or the intermediate-risk group according to Wells score and the revised Geneva score. Noteworthy, 105/1001 (10.5%) and 107/1001 (10.7%) of the CTPAs were inappropriately ordered according to the Wells score and the revised Geneva score. Altogether 168/1001 (16.8%) could theoretically be avoided. CONCLUSIONS This study highlights scant utilization of guideline-recommended risk-stratification tools in CTPA use at the emergency department.
Collapse
Affiliation(s)
- Juha Matias Kauppi
- Emergency Clinic, Turku University Hospital, Savitehtaankatu 1, 20540 Turku, Finland
| | | | - Juuso Saha
- University of Turku, Turku FI-20014, Finland
| | | | | | | | - Samuli Jaakkola
- Heart Centre, Turku University Hospital, 20521 Turku, Finland
| | - Jarmo Lehtonen
- Emergency Clinic, Turku University Hospital, Savitehtaankatu 1, 20540 Turku, Finland
| | - Tuija Vasankari
- Heart Centre, Turku University Hospital, 20521 Turku, Finland
| | - Markus Juonala
- Department of Medicine, University of Turku, FI-20521, Finland
- Division of Medicine, Turku University Hospital, Turku FI-20521, Finland
| | | |
Collapse
|
26
|
Ahuja J, Palacio D, Jo N, Strange CD, Shroff GS, Truong MT, Wu CC. Pitfalls in the imaging of pulmonary embolism. Semin Ultrasound CT MR 2022; 43:221-229. [PMID: 35688533 DOI: 10.1053/j.sult.2022.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Pulmonary embolism (PE) can present with a wide spectrum of clinical symptoms that can overlap considerably with other cardiovascular diseases. To avoid PE related morbidity and mortality, it is vital to identify this disease accurately and in a timely fashion. Several clinical criteria have been developed to standardize the diagnostic approach for patients with suspected PE. Computed tomographic pulmonary angiogram has significantly improved the detection of pulmonary embolism and is considered the imaging modality of choice to diagnose this disease. However, there are several potential pitfalls associated with this modality which can make diagnosis of PE challenging. In this review, we will discuss various pitfalls routinely encountered in the diagnostic work up of patients with suspected PE, approaches to mitigate these pitfalls and incidental pulmonary embolism.
Collapse
Affiliation(s)
- Jitesh Ahuja
- Department of Thoracic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Diana Palacio
- Department of Radiology, The University of Texas Medical Branch, UTMB. Galveston TX
| | - Nahyun Jo
- Department of Radiology, The University of Texas Medical Branch, UTMB. Galveston TX
| | - Chad D Strange
- Department of Thoracic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Girish S Shroff
- Department of Thoracic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Mylene T Truong
- Department of Thoracic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Carol C Wu
- Department of Thoracic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX
| |
Collapse
|
27
|
A novel methodological framework was described for detecting and quantifying overdiagnosis. J Clin Epidemiol 2022; 148:146-159. [PMID: 35483550 DOI: 10.1016/j.jclinepi.2022.04.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 04/12/2022] [Accepted: 04/20/2022] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Methods to quantify overdiagnosis of screen detected cancer have been developed, but methods for quantifying overdiagnosis of non-cancer conditions (whether symptomatic or asymptomatic) have been lacking. We aimed to develop a methodological framework for quantifying overdiagnosis that may be used for asymptomatic or symptomatic conditions, and used Gestational Diabetes Mellitus as an example of how it may be applied. STUDY DESIGN AND SETTING We identify two earlier definitions for overdiagnosis, a narrower prognosis-based definition, and a wider utility-based definition. Building on the central importance of the concepts of prognostic information and clinical utility of a diagnosis, we consider the following questions: within a target population, do people found to have a disease using one diagnostic strategy but found not to have the disease using another diagnostic strategy (so called 'additional diagnoses'), have an increased risk of adverse clinical outcomes without treatment (prognosis evidence), and/or a decreased risk of adverse outcomes with treatment (utility evidence)? RESULTS Using Causal Directed Acyclic Graphs and Fair Umpires, we illuminate the relationships between diagnostics strategies and the frequency of overdiagnosis. We then use the example of Gestational Diabetes Mellitus to demonstrate how the Fair Umpire framework may be applied to estimate overdiagnosis. CONCLUSION Our framework may be used to quantify overdiagnosis in non-cancer conditions (and in cancer conditions), as well as to guide further studies on this topic.
Collapse
|
28
|
Lavon O, Tamir T. Evaluation of the Padua Prediction Score ability to predict venous thromboembolism in Israeli non-surgical hospitalized patients using electronic medical records. Sci Rep 2022; 12:6121. [PMID: 35414101 PMCID: PMC9005505 DOI: 10.1038/s41598-022-10209-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 03/25/2022] [Indexed: 11/09/2022] Open
Abstract
Venous thromboembolism (VTE) is considered a leading safety concern during hospitalization. The Padua Predication Score (PPS) is a risk model conceived to predict VTE among non-surgical hospitalized patients. The study aim was to evaluate the PPS ability to predict VTE in Israeli non-surgical hospitalized patients using data from electronic medical records. A single center, large-scale, historic cohort study of hospitalized non-surgical patients was conducted. Outcomes included clinically diagnosed symptomatic VTE events, bleeding events, and mortality during hospitalization and up to 90 days thereafter, and readmission up to 90 days after discharge. 5117 patient records were analyzed after screening and validation. 1120 (22%) patients were defined per PPS as high-risk, of which 277 (24.7%) were prophylactically treated. The low-risk group included 3997 (78%) patients. Prevalence of symptomatic VTE was low. Overall, 14 (0.27%) VTE events were diagnosed: 3 cases in the high-risk group (0.27%) and 11 (0.28%) in the low-risk group, with no significant difference, p = 0.768. Prophylactic treatment among the high-risk patients did not significantly improve VTE incidence: 1/277 (0.36%) treated vs. 2/843 (0.24%), p = 0.343. There was no significant difference between the study groups regarding the rates of bleeding, unexplained mortality or readmission. PPS was not found to be an efficient tool for identification of non-surgical hospitalized patients with high risk for clinically significant VTE.
Collapse
Affiliation(s)
- O Lavon
- Clinical Pharmacology and Toxicology Unit, Carmel Medical Center, Michal St. 7, 3436212, Haifa, Israel. .,Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.
| | - T Tamir
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| |
Collapse
|
29
|
Castañer E, Gonzalez A, Andreu M, Lozano C, Gallardo X. Influence of using recommended radiological criteria on MDCT-angiography diagnosis of single isolated subsegmental pulmonary embolism. Eur Radiol 2022; 32:4284-4291. [PMID: 35032211 DOI: 10.1007/s00330-021-08480-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 10/18/2021] [Accepted: 11/23/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We assessed the rate of false-positive diagnoses of MDCT-pulmonary angiography (MDCT-A) in patients with single isolated subsegmental pulmonary embolism (SISSPE). METHODS All patients who underwent MDCT-A between 2006 and 2017 for ruling out acute pulmonary embolism (PE) and received an initial diagnosis of SISSPE were included. The MDCT-A of these patients were reviewed retrospectively by four experienced thoracic radiologists, who applied radiological criteria recommended by the American College of Chest Physicians Antithrombotic Guidelines (ACCP 2016) for the diagnosis of SISSPE. Data extracted from medical records were history of venous thromboembolism (VTE), alternative diagnoses, other diagnostic studies for VTE, anticoagulation, bleeding complications, and VTE over the following 3 months. RESULTS Of 3839 patients undergoing MDCT-A, PE was found in 1021 (26.6%) and SISSPE in 59 (1.5% overall and 5.8% of all patients with PE). An alternative diagnosis to PE was made on the basis of CT in 33 (55.9%) patients. Forty-one (69.5%) patients received anticoagulants, and major life-threatening bleeding complications occurred in 2, with one death. Recurrent PE was not documented in any patient with SISSPE. In the retrospective assessment of the 59 cases of SISSPE, 21 were negative for PE, with a false-positive rate of 35.6% (21/59); so the percentage of SISSPE cases after the revision was 3.7% of all patients with PE; 11 of these 21 patients received anticoagulation. CONCLUSIONS Radiologists should be aware of the high rate of false-positives when making the diagnosis of SISSPE on MDCT-A without using strict diagnostic criteria. Misdiagnosis exposes patients to unnecessary anticoagulation. KEY POINTS • Radiologist should be aware of the high rate of false-positive diagnoses of single isolated subsegmental pulmonary embolism (SISSPE) in MDCT-pulmonary angiography (MDCT-A) performed for ruling out pulmonary embolism. • Misdiagnosis of SISSPE in MDCT-A can be reduced by using strict diagnostic radiological criteria recommended by the American College of Chest Physicians Antithrombotic Guidelines. • Unnecessary anticoagulation therapy with potential severe bleeding complications may result from misdiagnosis of SISSPE.
Collapse
Affiliation(s)
- Eva Castañer
- Servei de Diagnòstic per la Imatge, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT), Universitat Autònoma de Barcelona, Parc Taulí 1, 08208, Sabadell, Barcelona, Spain.
| | - Amàlia Gonzalez
- Servei de Diagnòstic per la Imatge, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT), Universitat Autònoma de Barcelona, Parc Taulí 1, 08208, Sabadell, Barcelona, Spain
| | - Marta Andreu
- Servei de Diagnòstic per la Imatge, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT), Universitat Autònoma de Barcelona, Parc Taulí 1, 08208, Sabadell, Barcelona, Spain
| | - Carme Lozano
- Servei de Diagnòstic per la Imatge, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT), Universitat Autònoma de Barcelona, Parc Taulí 1, 08208, Sabadell, Barcelona, Spain
| | - Xavier Gallardo
- Servei de Diagnòstic per la Imatge, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT), Universitat Autònoma de Barcelona, Parc Taulí 1, 08208, Sabadell, Barcelona, Spain
| |
Collapse
|
30
|
Fatemi Y, Bergl PA. Diagnostic Stewardship: Appropriate Testing and Judicious Treatments. Crit Care Clin 2021; 38:69-87. [PMID: 34794632 DOI: 10.1016/j.ccc.2021.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Diagnostic stewardship encompasses the entire diagnosis-to-treatment paradigm in the intensive care unit (ICU). Initially born of the antimicrobial stewardship movement, contemporary diagnostic stewardship aims to promote timely and appropriate diagnostic testing that directly links to management decisions. In the stewardship framework, excessive diagnostic testing in low probability cases is discouraged due to its tendency to generate false-positive results, which have their own downstream consequences. Though the evidence basis for diagnostic stewardship initiatives in the ICU is nascent and largely limited to retrospective analyses, available literature generally suggests that these initiatives are safe, feasible, and associated with similar patient outcomes. As diagnostic testing of critically ill patients becomes increasingly sophisticated in the ensuing decade, a stewardship mindset will aid bedside clinicians in interpreting and incorporating new diagnostic strategies in the ICU.
Collapse
Affiliation(s)
- Yasaman Fatemi
- Division of Infectious Diseases, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA.
| | - Paul A Bergl
- Department of Critical Care, Gundersen Lutheran Medical Center, 1900 South Avenue, Mail Stop LM3-001, La Crosse, WI 54601, USA; Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| |
Collapse
|
31
|
CT pulmonary angiography appropriateness in a single emergency department: does the use of revised Geneva score matter? Radiol Med 2021; 126:1544-1552. [PMID: 34518985 PMCID: PMC8702417 DOI: 10.1007/s11547-021-01416-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 08/30/2021] [Indexed: 12/24/2022]
Abstract
PURPOSE To assess the percentage of computed tomography pulmonary angiography (CTPA) procedures that could have been avoided by methodical application of the Revised Geneva Score (RGS) coupled with age-adjusted D-dimer cut-offs rather than only clinical judgment in Emergency Department patients with suspected pulmonary embolism (PE). MATERIAL AND METHODS Between November 2019 and May 2020, 437 patients with suspected PE based on symptoms and D-dimer test were included in this study. All patients underwent to CTPA. For each patient, we retrospectively calculated the age-adjusted D-dimer cut-offs and the RGS in the original version. Finally, CT images were retrospectively reviewed, and the presence of PE was recorded. RESULTS In total, 43 (9.84%) CTPA could have been avoided by use of RGS coupled with age-adjusted D-dimer cut-offs. Prevalence of PE was 14.87%. From the analysis of 43 inappropriate CTPA, 24 (55.81%) of patients did not show any thoracic signs, two (4.65%) of patients had PE, and the remaining patients had alternative thoracic findings. CONCLUSION The study showed good prevalence of PE diagnoses in our department using only physician assessment, although 9.84% CTPA could have been avoided by methodical application of RGS coupled with age-adjusted D-dimer cut-offs.
Collapse
|
32
|
Andruchow JE, Grigat D, McRae AD, Innes G, Vatanpour S, Wang D, Taljaard M, Lang E. Decision support for computed tomography in the emergency department: a multicenter cluster-randomized controlled trial. CAN J EMERG MED 2021; 23:631-640. [PMID: 34351598 DOI: 10.1007/s43678-021-00170-3] [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: 03/25/2021] [Accepted: 06/17/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Clinical decision support may facilitate evidence-based imaging, but most studies to date examining the impact of decision support have used non-randomized designs which limit the conclusions that can be drawn from them. This randomized trial examines if decision support can reduce computed tomography (CT) utilization for patients with mild traumatic brain injuries and suspected pulmonary embolism in the emergency department. This study was funded by a competitive public research grant and registered on ClinicalTrials.gov (NCT02410941). METHODS Emergency physicians at five urban sites were assigned to voluntary decision support for CT imaging of patients with either head injuries or suspected pulmonary embolism using a cluster-randomized design over a 1-year intervention period. The co-primary outcomes were CT head and CT pulmonary angiography utilization. CT pulmonary angiography diagnostic yield (proportion of studies diagnostic for acute pulmonary embolism) was a secondary outcome. RESULTS A total of 225 physicians were randomized and studied over a 2-year baseline and 1-year intervention period. Physicians interacted with the decision support in 38.0% and 45.0% of eligible head injury and suspected pulmonary embolism cases, respectively. A mixed effects logistic regression model demonstrated no significant impact of decision support on head CT utilization (OR 0.93, 95% CI 0.79-1.10, p = 0.31), CT pulmonary angiography utilization (OR 0.98, 95% CI 0.88-1.11, p = 0.74) or diagnostic yield (OR 1.23, 95% CI 0.96-1.65, p = 0.10). However, overall CT pulmonary diagnostic yield (17.7%) was almost three times higher than that reported by a recent large US study, suggesting that selective imaging was already being employed. CONCLUSION Voluntary decision support addressing many commonly cited barriers to evidence-based imaging did not significantly reduce CT utilization or improve diagnostic yield but was limited by low rates of participation and high baseline rates of selective imaging. Demonstrating value to clinicians through interventions that improve workflow is likely necessary to meaningfully change imaging practices.
Collapse
Affiliation(s)
- James E Andruchow
- Department of Emergency Medicine, University of Calgary Cumming School of Medicine, Foothills Medical Centre Room C-231, 1403-29st NW, Calgary, AB, T2N 2T9, Canada. .,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
| | | | - Andrew D McRae
- Department of Emergency Medicine, University of Calgary Cumming School of Medicine, Foothills Medical Centre Room C-231, 1403-29st NW, Calgary, AB, T2N 2T9, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Grant Innes
- Department of Emergency Medicine, University of Calgary Cumming School of Medicine, Foothills Medical Centre Room C-231, 1403-29st NW, Calgary, AB, T2N 2T9, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Shabnam Vatanpour
- Department of Emergency Medicine, University of Calgary Cumming School of Medicine, Foothills Medical Centre Room C-231, 1403-29st NW, Calgary, AB, T2N 2T9, Canada
| | - Dongmei Wang
- Department of Emergency Medicine, University of Calgary Cumming School of Medicine, Foothills Medical Centre Room C-231, 1403-29st NW, Calgary, AB, T2N 2T9, Canada
| | - Monica Taljaard
- Ottawa Hospital Research Institute, Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Eddy Lang
- Department of Emergency Medicine, University of Calgary Cumming School of Medicine, Foothills Medical Centre Room C-231, 1403-29st NW, Calgary, AB, T2N 2T9, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| |
Collapse
|
33
|
Stevens SM, Woller SC, Baumann Kreuziger L, Bounameaux H, Doerschug K, Geersing GJ, Huisman MV, Kearon C, King CS, Knighton AJ, Lake E, Murin S, Vintch JRE, Wells PS, Moores LK. Antithrombotic Therapy for VTE Disease: Second Update of the CHEST Guideline and Expert Panel Report. Chest 2021; 160:e545-e608. [PMID: 34352278 DOI: 10.1016/j.chest.2021.07.055] [Citation(s) in RCA: 385] [Impact Index Per Article: 128.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 06/11/2021] [Accepted: 07/08/2021] [Indexed: 01/06/2023] Open
|
34
|
Pellegrini JAS, Rech TH, Schwarz P, de Oliveira ACT, Vieceli T, Moraes RB, Sekine L, Viana MV. Incidence of venous thromboembolism among patients with severe COVID-19 requiring mechanical ventilation compared to other causes of respiratory failure: a prospective cohort study. J Thromb Thrombolysis 2021; 52:482-492. [PMID: 33599858 PMCID: PMC7890785 DOI: 10.1007/s11239-021-02395-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/06/2021] [Indexed: 12/11/2022]
Abstract
Previous studies have suggested that COVID-19 pneumonia is associated with an increased risk of venous thromboembolism (VTE). This study aimed to investigate the incidence of VTE among mechanically ventilated adults with COVID-19 pneumonia, compared to patients with respiratory failure related to other causes. Prospective study that enrolled critically ill adults with suspected COVID-19 pneumonia between June 2, 2020 and August 11, 2020. Critically ill adults with suspected COVID-19 pneumonia who required mechanical ventilation within 24 h after hospital admission were followed until death or hospital discharge. Sequential ultrasonography screening of the lower extremities and catheter insertion sites, as well as testing for plasma biochemical markers, were performed at the intensive care unit admission, day 3, day 7, and day 14. The primary outcome was a composite of deep venous thrombosis, pulmonary embolism, and thrombosis at the central catheter insertion sites. We enrolled 70 patients, including 57 patients with COVID-19 and 13 patients without COVID-19, and all patients completed follow-up. The incidence of the primary outcome was higher among patients with COVID-19 than among patients with respiratory failure related to other etiologies (36.8% vs. 0%, p = 0.023). Multivariate regression analysis revealed that VTE was independently associated with a COVID-19 diagnosis (odds ratio: 6.28, 95% confidence interval: 1.19–68.07) and D-dimer concentration (1-ng/mL increase, odds ratio: 1.15, 95% confidence interval: 1.05–1.30). The incidence of VTE was higher among critically ill mechanically ventilated patients, relative to among patients with respiratory failure related to other causes.
Collapse
Affiliation(s)
| | - Tatiana Helena Rech
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Ramiro Barcelos 2400, Porto Alegre, RS, 90035-003, Brazil.,Post-Graduate Program in Medical Sciences: Endocrinology, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, RS, Brazil
| | - Patrícia Schwarz
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Ramiro Barcelos 2400, Porto Alegre, RS, 90035-003, Brazil
| | | | - Tarsila Vieceli
- Internal Medicine Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
| | - Rafael Barberena Moraes
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Ramiro Barcelos 2400, Porto Alegre, RS, 90035-003, Brazil.,Post-Graduate Program in Medical Sciences: Pneumology, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, RS, Brazil
| | - Leo Sekine
- Transfusion Medicine Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil.,Post-Graduate Program in Medical Sciences, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, RS, Brazil
| | - Marina Verçoza Viana
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Ramiro Barcelos 2400, Porto Alegre, RS, 90035-003, Brazil.
| |
Collapse
|
35
|
Coon ER, Newman TB, Hall M, Wilkes J, Bratton SL, Schroeder AR. Trends in Imaging Findings, Interventions, and Outcomes Among Children With Isolated Head Trauma. Pediatr Emerg Care 2021; 37:55-61. [PMID: 29698347 PMCID: PMC8758286 DOI: 10.1097/pec.0000000000001475] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE The aim was to analyze the impact of decreased head computed tomography (CT) imaging on detection of abnormalities and outcomes for children with isolated head trauma. METHODS The study involves a multicenter retrospective cohort of patients younger than 19 years presenting for isolated head trauma to emergency departments in the Pediatric Health Information System database from 2003 to 2015. Patients directly admitted or transferred to another facility and those with a discharge diagnosis code for child maltreatment were excluded. Outcomes were ascertained from administrative and billing data. Trends were tested using mixed effects logistic regression, accounting for clustering within hospitals and adjusted for age, sex, insurance type, race, presence of a complex chronic condition, and hospital-level case mix index. RESULTS Between 2003 and 2015, 306,041 children presented for isolated head trauma. The proportion of children receiving head CT imaging was increasing until 2008, peaking at just under 40%, before declining to 25% by 2015. During the recent period of decreased head CT imaging, the detection of skull fractures (odds ratio [OR]/year, 0.96; 95% confidence interval [CI], 0.95-0.97) and intracranial bleeds (OR/year, 0.96; 95% CI, 0.94-0.97), hospitalization (OR/year, 0.96; 95% CI, 0.95-0.96), neurosurgery (OR/year, 0.91; 95% CI, 0.87-0.95), and revisit (OR/year, 0.98; 95% CI, 0.96-1.00) also decreased, without significant changes in mortality (OR/year, 0.93; 95% CI, 0.84-1.04) or persistent neurologic impairment (OR/year, 1.03; 95% CI, 0.92-1.15). CONCLUSIONS The recent decline in CT scanning in children with isolated head trauma was associated with a reduction in detection of intracranial abnormalities, and a concomitant decrease in interventions, without measurable patient harm.
Collapse
Affiliation(s)
- Eric R. Coon
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Thomas B. Newman
- Departments of Epidemiology and Biostatistics and Pediatrics, University of California, San Francisco
| | - Matt Hall
- Children’s Hospital Association, Lenexa, KS
| | - Jacob Wilkes
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Susan L. Bratton
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | | |
Collapse
|
36
|
Baumgartner C, Tritschler T. Clinical significance of subsegmental pulmonary embolism: An ongoing controversy. Res Pract Thromb Haemost 2021; 5:14-16. [PMID: 33537525 PMCID: PMC7845080 DOI: 10.1002/rth2.12464] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 11/08/2020] [Accepted: 11/13/2020] [Indexed: 11/18/2022] Open
Affiliation(s)
- Christine Baumgartner
- Department of General Internal Medicine, InselspitalBern University HospitalUniversity of BernBernSwitzerland
| | - Tobias Tritschler
- Department of General Internal Medicine, InselspitalBern University HospitalUniversity of BernBernSwitzerland
| |
Collapse
|
37
|
Fernández‐Capitán C, Rodriguez Cobo A, Jiménez D, Madridano O, Ciammaichella M, Usandizaga E, Otero R, Di Micco P, Moustafa F, Monreal M. Symptomatic subsegmental versus more central pulmonary embolism: Clinical outcomes during anticoagulation. Res Pract Thromb Haemost 2021; 5:168-178. [PMID: 33537541 PMCID: PMC7845079 DOI: 10.1002/rth2.12446] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 10/01/2020] [Accepted: 10/07/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The optimal therapy of patients with acute subsegmental pulmonary embolism (PE) is controversial. METHODS We used the RIETE (Registro Informatizado Enfermedad TromboEmbólica) database to compare the rate of symptomatic PE recurrences during anticoagulation in patients with subsegmental, segmental, or more central PEs. RESULTS Among 15 963 patients with a first episode of symptomatic PE, 834 (5.2%) had subsegmental PE, 3797 (24%) segmental, and 11 332 (71%) more central PE. Most patients in all subgroups received initial therapy with low-molecular-weight heparin, and then most switched to vitamin K antagonists. Median duration of therapy was 179, 185, and 204 days, respectively. During anticoagulation, 183 patients developed PE recurrences, 131 developed deep vein thrombosis (DVT), 543 bled, and 1718 died (fatal PE, 135). The rate of PE recurrences was twofold higher in patients with subsegmental PE than in those with segmental (hazard ratio [HR], 2.13; 95% confidence interval [CI], 1.16-3.85) or more central PE (HR, 1.89; 95% CI, 1.12-3.13). On multivariable analysis, patients with subsegmental PE had a higher risk for PE recurrences than those with central PE (adjusted HR, 1.75; 95% CI, 1.02-3.03). After stratifying patients with subsegmental PE according to ultrasound imaging in the lower limbs, the rate of PE recurrences was similar in patients with DVT, in patients without DVT, and in those with no ultrasound imaging. CONCLUSIONS Our study reveals that the risk for PE recurrences in patients with segmental PE is not lower than in those with more central PE, thus suggesting that the risk of PE recurrences is not influenced by the anatomic location of PE.
Collapse
Affiliation(s)
| | - Ana Rodriguez Cobo
- Department of Internal MedicineHospital de Madrid Norte SanchinarroMadridSpain
| | - David Jiménez
- Respiratory DepartmentRamón y Cajal Hospital and Instituto Ramón y Cajal de Investigación Sanitaria IRYCISMadridSpain
| | - Olga Madridano
- Department of Internal MedicineHospital Infanta SofíaMadridSpain
| | | | - Esther Usandizaga
- Department of Internal MedicineHospital de Sant Joan Despí Moises BroggiBarcelonaSpain
| | - Remedios Otero
- Department of PneumonologyHospital Universitario Virgen del RocíoSevillaSpain
| | - Pierpaolo Di Micco
- Department of Internal Medicine and Emergency RoomOspedale Buon Consiglio FatebenefratelliNaplesItaly
| | - Farès Moustafa
- Department of EmergencyClermont‐Ferrand University HospitalClermont‐FerrandFrance
| | - Manuel Monreal
- Department of Internal MedicineHospital de Badalona Germans Trias i PujolUniversidad Católica de MurciaMurciaSpain
| |
Collapse
|
38
|
Wang RC, Miglioretti DL, Marlow EC, Kwan ML, Theis MK, Bowles EJA, Greenlee RT, Rahm AK, Stout NK, Weinmann S, Smith-Bindman R. Trends in Imaging for Suspected Pulmonary Embolism Across US Health Care Systems, 2004 to 2016. JAMA Netw Open 2020; 3:e2026930. [PMID: 33216141 PMCID: PMC7679949 DOI: 10.1001/jamanetworkopen.2020.26930] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE In response to calls to reduce unnecessary diagnostic testing with computed tomographic pulmonary angiography (CTPA) for suspected pulmonary embolism (PE), there have been growing efforts to create and implement decision rules for PE testing. It is unclear if the use of advanced imaging tests for PE has diminished over time. OBJECTIVE To assess the use of advanced imaging tests, including chest computed tomography (CT) (ie, all chest CT except for CTPA), CTPA, and ventilation-perfusion (V/Q) scan, for PE from 2004 to 2016. DESIGN, SETTING, AND PARTICIPANTS Cohort study of adults by age group (18-64 years and ≥65 years) enrolled in 7 US integrated and mixed-model health care systems. Joinpoint regression analysis was used to identify years with statistically significant changes in imaging rates and to calculate average annual percentage change (growth) from 2004 to 2007, 2008 to 2011, and 2012 to 2016. Analyses were conducted between June 11, 2019, and March 18, 2020. MAIN OUTCOMES AND MEASURES Rates of chest CT, CTPA, and V/Q scan by year and age, as well as annual change in rates over time. RESULTS Overall, 3.6 to 4.8 million enrollees were included each year of the study, for a total of 52 343 517 person-years of follow-up data. Adults aged 18 to 64 years accounted for 42 223 712 person-years (80.7%) and those 65 years or older accounted for 10 119 805 person-years (19.3%). Female enrollees accounted for 27 712 571 person-years (52.9%). From 2004 and 2016, chest CT use increased by 66.3% (average annual growth, 4.4% per year), CTPA use increased by 450.0% (average annual growth, 16.3% per year), and V/Q scan use decreased by 47.1% (decreasing by 4.9% per year). The use of CTPA increased most rapidly from 2004 to 2006 (44.6% in those aged 18-64 years and 43.9% in those ≥65 years), with ongoing rapid growth from 2006 to 2010 (annual growth, 19.8% in those aged 18-64 years and 18.3% in those ≥65 years) and persistent but slower growth in the most recent years (annual growth, 4.3% in those aged 18-64 years and 3.0% in those ≥65 years from 2010 to 2016). The use of V/Q scanning decreased steadily since 2004. CONCLUSIONS AND RELEVANCE From 2004 to 2016, rates of chest CT and CTPA for suspected PE continued to increase among adults but at a slower pace in more contemporary years. Efforts to combat overuse have not been completely successful as reflected by ongoing growth, rather than decline, of chest CT use. Whether the observed imaging use was appropriate or was associated with improved patient outcomes is unknown.
Collapse
Affiliation(s)
- Ralph C. Wang
- Department of Emergency Medicine, University of California, San Francisco
| | - Diana L. Miglioretti
- Department of Public Health Sciences, University of California, Davis
- Comprehensive Cancer Center, University of California, Davis
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle
| | - Emily C. Marlow
- Department of Public Health Sciences, University of California, Davis
| | - Marilyn L. Kwan
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - May K. Theis
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle
| | - Erin J. A. Bowles
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle
| | - Robert T. Greenlee
- Marshfield Clinic Research Institute, Marshfield Clinic Health System, Marshfield, Wisconsin
| | - Alanna K. Rahm
- Genomic Medicine Institute, Geisinger, Danville, Pennsylvania
| | - Natasha K. Stout
- Massachusetts Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston
| | - Sheila Weinmann
- now with Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
- Center for Integrated Health Research, Kaiser Permanente Hawaii, Honolulu
| | - Rebecca Smith-Bindman
- Department of Radiology and Biomedical Imaging, University of California, San Francisco
- Department of Epidemiology and Biostatistics, University of California, San Francisco
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
| |
Collapse
|
39
|
Richmond C, Jolly H, Isles C. Syncope in pulmonary embolism: a retrospective cohort study. Postgrad Med J 2020; 97:789-791. [PMID: 33040028 DOI: 10.1136/postgradmedj-2020-138677] [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: 07/20/2020] [Revised: 08/24/2020] [Accepted: 09/04/2020] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To determine the prevalence of syncope or collapse in pulmonary embolism (PE). METHODS A retrospective cohort study was conducted. We examined the frequency with which syncope or collapse (presyncope) occurred alone or with other symptoms and signs in an unselected series of 224 patients presenting to a district general hospital with PE between September 2012 and March 2016. Confirmation of PE was by CT pulmonary angiogram in each case. RESULTS Our cohort of 224 patients comprised 97 men and 127 women, average age 66 years with age range of 21-94 years. Syncope or collapse was one of several symptoms and signs that led to a diagnosis of PE in 22 patients (9.8%) but was never the sole presenting feature. In descending order, these other clinical features were hypoxaemia (17 patients), dyspnoea (12), chest pain (9), tachycardia (7) and tachypnoea (7). ECG abnormalities reported to occur more commonly in PE were found in 13/17 patients for whom ECGs were available. Patients with PE presenting with syncope or collapse were judged to have a large clot load in 15/22 (68%) cases. CONCLUSION Syncope was a frequent presenting symptom in our study of 224 consecutive patients with PE but was never the sole clinical feature. It would be difficult to justify routine testing for PE in patients presenting only with syncope or collapse.
Collapse
Affiliation(s)
- Craig Richmond
- Medical Unit, Dumfries and Galloway Royal Infirmary, Dumfries, UK
| | - Hannah Jolly
- Medical Unit, Dumfries and Galloway Royal Infirmary, Dumfries, UK
| | - Chris Isles
- Medical Unit, Dumfries and Galloway Royal Infirmary, Dumfries, UK
| |
Collapse
|
40
|
Predictors of positive computed tomography pulmonary angiography results. Emerg Radiol 2020; 27:503-511. [DOI: 10.1007/s10140-020-01793-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 05/14/2020] [Indexed: 10/24/2022]
|
41
|
Investigation of pulmonary embolism in patients with chest pain in the emergency department: a retrospective multicenter study. Eur J Emerg Med 2020; 27:357-361. [PMID: 32097173 DOI: 10.1097/mej.0000000000000680] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Chest pain is a common main complaint in the emergency department. Among its associated differential diagnoses, pulmonary embolism remains a key concern for the clinician. There are no clear recommendations on which patients should have a formal workup for pulmonary embolism diagnosis. The objective of this study was to determine the proportion of patients with chest pain who were investigated for pulmonary embolism diagnosis and to determine the clinical profile of these patients. METHODS This was a retrospective multicenter study conducted in three French Emergency Departments. We included all patients who presented to these centers for chest pain during a 2-month period. The primary outcome was the initiation of pulmonary embolism workup. We also aimed to find factors associated with this outcome. RESULTS We included 881 patients with a main complaint of chest pain. Mean age was 50 years and 481 (56%) were men. A total of 263 patients (30%, 95% confidence interval 27-33%) had a formal pulmonary embolism workup, and pulmonary embolism was ultimately diagnosed in 7 cases (prevalence of 2.6%, 95% confidence interval 1.1-5.3%). Five factors were identified as independently associated with a workup for pulmonary embolism diagnosis: female sex, young age, no ischemic heart disease, recent flight and associated dyspnea. CONCLUSION Among patients presenting to emergency department with chest pain, 30% had a workup for pulmonary embolism. We report five clinical variables independently associated with a higher probability of pulmonary embolism workup in our sample.
Collapse
|
42
|
Gupta P, Gupta M, Koul N. Overdiagnosis and overtreatment; how to deal with too much medicine. J Family Med Prim Care 2020; 9:3815-3819. [PMID: 33110773 PMCID: PMC7586591 DOI: 10.4103/jfmpc.jfmpc_433_20] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 04/25/2020] [Accepted: 05/18/2020] [Indexed: 12/26/2022] Open
Abstract
The past few decades have seen medical science making rapid strides in the field of diagnostic technologies, thus making it possible to detect some conditions at a very early stage. An unwanted effect of these developments is overdiagnosis which occurs when a true abnormality is discovered, but detection of that abnormality and its treatment does not benefit the patient. Overdiagnosis is encountered as a result cancer screening, in genetic diseases and in some chronic conditions when disease definition is broadened. There is urgent need of development of evidence based decision-making tools for clinicians which will help patients understand the benefits and harms of different screening and treatment methods. And the treating physician has to play a important role to convince the patient that watchful waiting, for some of the lesions may be the best option available in some circumstances.
Collapse
Affiliation(s)
- Puneeta Gupta
- Department of Medicine, Acharya Shri Chander College of Medical Sciences and Hospital, Jammu, J&K, India
| | - Meeta Gupta
- Department of Obstetrics and Gynaecology, Acharya Shri Chander College of Medical Sciences and Hospital, Jammu, J&K, India
| | - Neeraj Koul
- Department of Surgery, Acharya Shri Chander College of Medical Sciences and Hospital, Jammu, J&K, India
| |
Collapse
|
43
|
Rozbroj T, Haas R, O'Connor DA, Thomas R, McCaffery K, Carter S, Buchbinder R. How do patients and the public understand overtesting and overdiagnosis? A protocol for a thematic meta-synthesis of qualitative research. BMJ Open 2020; 10:e037283. [PMID: 32636285 PMCID: PMC7342480 DOI: 10.1136/bmjopen-2020-037283] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Examining patient and public understanding of overtesting and overdiagnosis (OverTD) is vital for reducing the burden of OverTD. Studies from disparate contexts, disciplines and focusing on disparate healthcare issues have examined patient and public understanding of OverTD. A synthesis is needed to bring this literature together, examine common themes, strengthen conclusions and identify gaps. This will help steer further research, policy and practice to improve patient and public understanding of OverTD. The objective of this study is to synthesise qualitative research data about patient and public understanding of OverTD. METHODS AND ANALYSIS A thematic meta-synthesis will be used to synthesise primary qualitative research and qualitative components of primary mixed-methods research about patient and public understanding of OverTD. Studies published in English will be included. These will be identified using systematic searches from inception to March 2020 in the Scopus, CINAHL, PsycINFO and MEDLINE databases. Studies that satisfy eligibility criteria will be assessed for methodological quality using the Critical Appraisal Skills Programme (CASP) checklist. Thematic meta-synthesis will comprise three stages: (1) line-by-line coding; (2) generation of descriptive themes and (3) generation of analytic themes. Confidence in the synthesis findings will be assessed using the Grading of Recommendations Assessment, Development and Evaluation Confidence in Evidence (GRADE CERQual) approach. A summary of GRADE CERQual results will be presented alongside the key themes. Study eligibility screening, data extraction, analysis and the CASP and GRADE CERQual assessments will be undertaken independently by two review authors. ETHICS AND DISSEMINATION Ethics approval is not required for this secondary analysis of published data. The results will be disseminated in peer-reviewed journals and may be presented in conference papers and elsewhere. PROSPERO REGISTRATION NUMBER CRD42020156838.
Collapse
Affiliation(s)
- Tomas Rozbroj
- Monash Department of Clinical Epidemiology, Cabrini Institute, Monash University, Clayton, Victoria, Australia
- Cabrini Institute, Cabrini Health, Malvern, Victoria, Australia
| | - Romi Haas
- Monash Department of Clinical Epidemiology, Cabrini Institute, Monash University, Clayton, Victoria, Australia
- Cabrini Institute, Cabrini Health, Malvern, Victoria, Australia
| | - Denise A O'Connor
- Monash Department of Clinical Epidemiology, Cabrini Institute, Monash University, Clayton, Victoria, Australia
- Cabrini Institute, Cabrini Health, Malvern, Victoria, Australia
| | - Rae Thomas
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Kirsten McCaffery
- Sydney School of Public Health, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Stacy Carter
- Australian Centre for Health Engagement, Evidence and Values, University of Wollongong, Wollongong, New South Wales, Australia
| | - Rachelle Buchbinder
- Monash Department of Clinical Epidemiology, Cabrini Institute, Monash University, Clayton, Victoria, Australia
- Cabrini Institute, Cabrini Health, Malvern, Victoria, Australia
| |
Collapse
|
44
|
Incidental pulmonary embolism in oncologic patients-a systematic review and meta-analysis. Support Care Cancer 2020; 29:1293-1302. [PMID: 32621266 PMCID: PMC7843533 DOI: 10.1007/s00520-020-05601-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 06/25/2020] [Indexed: 02/06/2023]
Abstract
Purpose Incidental pulmonary embolism (IPE) is a common finding on computed tomography (CT). IPE is frequent in oncologic patients undergoing staging CT. The aim of this analysis was to provide the pooled frequency of IPE and frequencies of IPE in different primary tumors. Methods MEDLINE, SCOPUS, and EMBASE databases were screened for studies investigating frequency of IPE in oncologic staging CT up to February 2020. Overall, 12 studies met the inclusion criteria and were included into the present study. Results The pooled analysis yielded a total of 28,626 patients. IPE was identified in 963 patients (3.36%, 95% CI = 3.15; 3.57). The highest frequency was found in prostate cancer (8.59%, 95%CI = 3.74; 13.44), followed by hepatobiliary carcinoma (6.07%, 95%CI = 3.09; 9.05) and pancreatic cancer (5.65%, 95%CI = 3.54; 7.76). The lowest frequencies were identified in tumors of male reproductive organs (0.79%, 95%CI = 0.21; 1.37) and hematological diseases (1.11% 95%CI = 0.74; 1.48). Conclusion The overall frequency of IPE in oncologic patients was 3.36%. There are considerable differences in regard to primary tumors with the highest frequency in prostate cancer and pancreatic and hepatobiliary carcinomas.
Collapse
|
45
|
Rech TH, Girardi AM, Gazzana MB. Incidence of pulmonary embolism in patients with COVID-19. Intensive Care Med 2020; 46:1500-1501. [PMID: 32435822 PMCID: PMC7237613 DOI: 10.1007/s00134-020-06081-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2020] [Indexed: 12/24/2022]
Affiliation(s)
- Tatiana Helena Rech
- Unidade de Terapia Intensiva, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil.
- Programa de Pós-Graduação Ciências Médicas: Endocrinologia, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.
| | - Adriana Muradás Girardi
- Programa de Pós-Graduação em Ciências Pneumológicas, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Marcelo Basso Gazzana
- Programa de Pós-Graduação em Ciências Pneumológicas, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
- Serviço de Pneumologia, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
| |
Collapse
|
46
|
Rokx C, Borjas Howard JF, Smit C, Wit FW, Pieterman ED, Reiss P, Cannegieter SC, Lijfering WM, Meijer K, Bierman W, Tichelaar V, Rijnders BJA. Risk of recurrent venous thromboembolism in patients with HIV infection: A nationwide cohort study. PLoS Med 2020; 17:e1003101. [PMID: 32407386 PMCID: PMC7224453 DOI: 10.1371/journal.pmed.1003101] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 04/13/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Multiple studies have described a higher incidence of venous thromboembolism (VTE) in people living with an HIV infection (PWH). However, data on the risk of recurrent VTE in this population are lacking, although this question is more important for clinical practice. This study aims to estimate the risk of recurrent VTE in PWH compared to controls and to identify risk factors for recurrence within this population. METHODS AND FINDINGS PWH with a first VTE were derived from the AIDS Therapy Evaluation in the Netherlands (ATHENA) cohort (2003-2015), a nationwide ongoing cohort following up PWH in care in the Netherlands. Uninfected controls were derived from the Multiple Environmental and Genetic Assessment of risk factors for venous thrombosis (MEGA) follow-up study (1999-2003), a cohort of patients with a first VTE who initially participated in a case-control study in the Netherlands who were followed up for recurrent VTE. Selection was limited to persons with an index VTE suffering from deep vein thrombosis in the lower limbs and/or pulmonary embolism (PE). Participants were followed from withdrawal of anticoagulation to VTE recurrence, loss to follow-up, death, or end of study. We estimated incidence rates, cumulative incidence (accounting for competing risk of death) and hazard ratios (HRs) using Cox proportional hazards regression, adjusting for age, sex, and whether the index event was provoked or unprovoked. When analyzing risk factors among PWH, the main focus of analysis was the role of immune markers (cluster of differentiation 4 [CD4]+ T-cell count). There were 153 PWH (82% men, median 48 years) and 4,005 uninfected controls (45% men, median 49 years) with a first VTE (71% unprovoked in PWH, 34% unprovoked in controls) available for analysis. With 40 VTE recurrences during 774 person-years of follow-up (PYFU) in PWH and 635 VTE recurrences during 20,215 PYFU in controls, the incidence rates were 5.2 and 3.1 per 100 PYFU (HR: 1.70, 95% CI 1.23-2.36, p = 0.003). VTE consistently recurred more frequently per 100 PYFU in PWH in all predefined subgroups of men (5.6 versus 4.8), women (3.6 versus 1.9), and unprovoked (6.0 versus 5.2) or provoked (3.1 versus 2.1) first VTE. After adjustment, the VTE recurrence risk was higher in PWH compared to controls in the first year after anticoagulant discontinuation (HR: 1.67, 95% CI 1.04-2.70, p = 0.03) with higher cumulative incidences in PWH at 1 year (12.5% versus 5.6%) and 5 years (23.4% versus 15.3%) of follow-up. VTE recurred less frequently in PWH who were more immunodeficient at the first VTE, marked by a better CD4+ T-cell recovery on antiretroviral therapy and during anticoagulant therapy for the first VTE (adjusted HR: 0.81 per 100 cells/mm3 increase, 95% CI 0.67-0.97, p = 0.02). Sensitivity analyses addressing potential sources of bias confirmed our principal analyses. The main study limitations are that VTEs were adjudicated differently in the cohorts and that diagnostic practices changed during the 20-year study period. CONCLUSIONS Overall, the risk of recurrent VTE was elevated in PWH compared to controls. Among PWH, recurrence risk appeared to decrease with greater CD4+ T-cell recovery after a first VTE. This is relevant when deciding to (dis)continue anticoagulant therapy in PWH with otherwise unprovoked first VTE.
Collapse
Affiliation(s)
- Casper Rokx
- Erasmus MC, University Medical Centre Rotterdam, Department of Internal Medicine, Section of Infectious Diseases, Rotterdam, the Netherlands
| | - Jaime F Borjas Howard
- University of Groningen, University Medical Centre Groningen, Department of Haematology, Groningen, the Netherlands
| | - Colette Smit
- HIV Monitoring Foundation, Amsterdam, the Netherlands
| | - Ferdinand W Wit
- Department of Global Health and Division of Infectious Diseases, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, the Netherlands
| | - Elise D Pieterman
- Erasmus MC, University Medical Centre Rotterdam, Department of Internal Medicine, Section of Infectious Diseases, Rotterdam, the Netherlands
| | - Peter Reiss
- Department of Global Health and Division of Infectious Diseases, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, the Netherlands
| | - Suzanne C Cannegieter
- Leiden University Medical Centre, Department of Clinical Epidemiology, Leiden, the Netherlands
| | - Willem M Lijfering
- Leiden University Medical Centre, Department of Clinical Epidemiology, Leiden, the Netherlands
| | - Karina Meijer
- University of Groningen, University Medical Centre Groningen, Department of Haematology, Groningen, the Netherlands
| | - Wouter Bierman
- University of Groningen, University Medical Centre Groningen, Department of Internal Medicine, Infectious Diseases Service, Groningen, the Netherlands
| | - Vladimir Tichelaar
- University of Groningen, University Medical Centre Groningen, Department of Haematology, Groningen, the Netherlands
| | - Bart J A Rijnders
- Erasmus MC, University Medical Centre Rotterdam, Department of Internal Medicine, Section of Infectious Diseases, Rotterdam, the Netherlands
| | | |
Collapse
|
47
|
Response to. Eur J Emerg Med 2020; 27:152-153. [DOI: 10.1097/mej.0000000000000665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
48
|
Lysdahlgaard S, Hess S, Gerke O, Weber Kusk M. A systematic literature review and meta-analysis of spectral CT compared to scintigraphy in the diagnosis of acute and chronic pulmonary embolisms. Eur Radiol 2020; 30:3624-3633. [PMID: 32112117 DOI: 10.1007/s00330-020-06735-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 12/20/2019] [Accepted: 02/07/2020] [Indexed: 01/26/2023]
Abstract
PURPOSE To examine the diagnostic accuracy of spectral CT pulmonary angiography (S-CTPA) using ventilation-perfusions lung scintigraphy (V/Q-scan) as a reference standard in the diagnosis of acute or chronic pulmonary embolism (APE/CPE) and chronic thromboembolic pulmonary hypertension (CTEPH). METHODS PubMed, Embase, Scopus, and Web of Science were searched for the period from 1 Jan 2006 to 7 Feb 2019; eligible studies had > 10 patients over 18 years old, a diagnostic outcome of PE or CTEPH, and used V/Q scan as a reference standard. Bias and applicability were assessed using QUADAS-2 tools. Sensitivities, specificities, and predictive values were noted or calculated from available information. Meta-analysis employed a fixed-effects model of Mantel and Haenszel. Heterogeneity was assessed with I-squared statistics. RESULTS Four hundred ninety-three unique records were identified. Following screening by title, 53 studies were included in the abstract and full-text assessment. A total of six articles were included; four were suitable for a meta-analysis. Pooled sensitivity was 94.2% (95% CI, 88.3-100%), pooled specificity was 88.5% (95% CI, 81.3-95.6%), and positive and negative predictive values were 87.8% (95% CI, 80.3-95.4%) and 94.5% (95% CI, 89.3-99.7%), respectively. CONCLUSION Data on S-CTPA for PE/CTEPH remains promising, but limited; only small studies with methodological issues are available. Evidence is best for CPE/CTEPH whereas no firm conclusions are possible for APE. There is a need for larger, prospective studies with a robust composite reference standard including state-of-the-art CTPA and V/Q-scans. KEY POINTS • S-CTPA has high sensitivity and specificity for perfusion defects in patients with PE or CPETH. • Methodological issues and diversity of reference standards were found in the small number of included studies. • There is a need for larger prospective studies with more robust composite reference standards.
Collapse
Affiliation(s)
- Simon Lysdahlgaard
- Department of Radiology and Nuclear Medicine, University Hospital of Southwest Jutland, Esbjerg, Denmark.
| | - Søren Hess
- Department of Radiology and Nuclear Medicine, University Hospital of Southwest Jutland, Esbjerg, Denmark
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Oke Gerke
- Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Martin Weber Kusk
- Department of Radiology and Nuclear Medicine, University Hospital of Southwest Jutland, Esbjerg, Denmark
| |
Collapse
|
49
|
Prevalence and Predictor of Pulmonary Embolism in a Cohort of Chinese Patients with Acute Proximal Deep Vein Thrombosis. Ann Vasc Surg 2020; 63:293-297. [DOI: 10.1016/j.avsg.2019.06.042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 06/08/2019] [Accepted: 06/30/2019] [Indexed: 11/18/2022]
|
50
|
Fang MC, Fan D, Sung SH, Witt DM, Schmelzer JR, Williams MS, Yale SH, Baumgartner C, Go AS. Treatment and Outcomes of Acute Pulmonary Embolism and Deep Venous Thrombosis: The CVRN VTE Study. Am J Med 2019; 132:1450-1457.e1. [PMID: 31247183 PMCID: PMC6917856 DOI: 10.1016/j.amjmed.2019.05.040] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 05/23/2019] [Accepted: 05/24/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Few studies describe both inpatient and outpatient treatment and outcomes of patients with acute venous thromboembolism in the United States. METHODS A multi-institutional cohort of patients diagnosed with confirmed pulmonary embolism or deep venous thrombosis during the years 2004 through 2010 was established from 4 large, US-based integrated health care delivery systems. Computerized databases were accessed and medical records reviewed to collect information on patient demographics, clinical risk factors, initial antithrombotic treatment, and vital status. Multivariable Cox regression models were used to estimate the risk of death at 90 days. RESULTS The cohort comprised 5497 adults with acute venous thromboembolism. Pulmonary embolism was predominantly managed in the hospital setting (95.0%), while 54.5% of patients with lower extremity thrombosis were treated as outpatients. Anticoagulant treatment differed according to thromboembolism type: 2688 patients (92.8%) with pulmonary embolism and 1625 patients (86.9%) with lower extremity thrombosis were discharged on anticoagulants, compared with 286 patients (80.1%) with upper extremity thrombosis and 69 (54.8%) patients with other thrombosis. While 4.5% of patients died during the index episode, 15.4% died within 90 days. Pulmonary embolism was associated with a higher 90-day death risk than lower extremity thrombosis (adjusted hazard ratio 1.23; 95% confidence interval, 1.04-1.47), as was not being discharged on anticoagulants (adjusted hazard ratio 5.56; 95% confidence interval, 4.76-6.67). CONCLUSIONS In this multicenter, community-based study of patients with acute venous thromboembolism, anticoagulant treatment and outcomes varied by thromboembolism type. Although case fatality during the acute episode was relatively low, 15.4% of people with thromboembolism died within 90 days of the index diagnosis.
Collapse
Affiliation(s)
- Margaret C Fang
- Division of Hospital Medicine, University of California, San Francisco.
| | - Dongjie Fan
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Sue Hee Sung
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Daniel M Witt
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City
| | | | | | - Steven H Yale
- Department of Medicine, University of Central Florida College of Medicine, Orlando
| | - Christine Baumgartner
- Division of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland; Departments of Epidemiology, Biostatistics and Medicine, University of California, San Francisco; Departments of Medicine, Health Research and Policy, Stanford University School of Medicine, Palo Alto, Calif
| |
Collapse
|