Diagnostic approach and use of CTPA in patients with suspected pulmonary embolism in an emergency department in Saudi Arabia

Proper application of anticoagulation therapy on cancer-associated venous thrombosis

Cancer-associated venous thromboembolism (VTE) significantly impacts morbidity and mortality. The introduction of direct oral anticoagulants over the past decade has revolutionized VTE treatment in patients with active cancer, offering potential advantages over traditional therapies. However, uncertainties persist regarding the optimal selection and dosage of anticoagulants, particularly in patients with specific risk factors for bleeding, such as certain cancer types (e.g., upper gastrointestinal cancer, genitourinary cancer, primary or metastatic brain tumor, and hematologic malignancies) and specific patient characteristics (e.g., renal dysfunction and thrombocytopenia). Recent data on the thrombotic risk associated with low thrombotic burden VTE, such as subsegmental pulmonary embolism and isolated distal deep vein thrombosis, underscore the need for updated management strategies in daily clinical practice. This review aims to explore these issues and highlight the evolving landscape of cancer-associated VTE management.

Low D-dimer in acute coronary syndrome and heart failure: Screening for large vessel diseases in patients with chest symptoms

Background

Distinguishing between large-vessel diseases such as acute aortic syndrome (AAS) and pulmonary embolism (PE), and non-large-vessel diseases, such as acute coronary syndrome (ACS), heart failure (HF), and neurogenic diseases, in patients presenting with chest symptoms remains a challenge, which can result in a significant number of misdiagnoses. Simultaneously distinguishing both AAS and PE is essential because large-vessel diseases require angio-computed tomography (CT) during initial presentation whereas, non-large-vessel diseases do not. This study aimed to determine the optimal method for differentiating between large-vessel and non-large-vessel diseases using D-dimer, troponin I, and pretest probability scores.

Methods

From the 11683 patients who presented with chest symptoms including chest pain, discomfort, or dyspnea, this retrospective observational study included 1817 patients who had complete data for essential biomarkers; 105 with AAS, 139 with PE, 1093 with ACS, 451 with HF, and 83 with neurogenic diseases.

Results

D-dimer, D-dimer/troponin I ratio (DT ratio), and troponin I results distinguished the 2 groups: D-dimer (>2.38 μg/mL), AUC 0.935; DT ratio, AUC 0.827; and troponin I, AUC 0.653. For predicting AAS, the performances of D-dimer level and aortic dissection detection risk score (ADD-RS) were AUCs of 0.915 (p < 0.0001) and 0.67 (p = 0.0004), respectively; for predicting PE, the AUCs of D-dimer level and modified Wells score were 0.95 (p = 0.0001) and 0.857 (p < 0.0001), respectively.

Conclusions

The D-dimer levels proved to be a crucial discriminator for identifying AAS and PE, even when compared with the ADD-RS and modified Wells scores. Moderately elevated D-dimer levels suggest the need to consider AAS and PE diagnoses via angio-CT for patients with chest symptoms.