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Remy-Jardin M, Oufriche I, Guiffault L, Duhamel A, Flohr T, Schmidt B, Remy J. Diagnosis of acute pulmonary embolism: when photon-counting-detector CT replaces energy-integrating-detector CT in daily routine. Eur Radiol 2024:10.1007/s00330-024-10724-5. [PMID: 38634875 DOI: 10.1007/s00330-024-10724-5] [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: 01/19/2024] [Revised: 02/22/2024] [Accepted: 03/06/2024] [Indexed: 04/19/2024]
Abstract
PURPOSE To compare the diagnostic approach of acute pulmonary embolism (PE) with photon-counting-detector CT (PCD-CT) and energy-integrating-detector CT (EID-CT). MATERIALS AND METHODS Two cohorts underwent CT angiographic examinations with EID-CT (Group 1; n = 158) and PCD-CT (Group 2; n = 172), (b) with two options in Group 1, dual energy (Group 1a) or single energy (Group 1b) and a single option in Group 2 (spectral imaging with single source). RESULTS In Group 2, all patients benefited from spectral imaging, only accessible to 105 patients (66.5%) in Group 1, with a mean acquisition time significantly shorter (0.9 ± 0.1 s vs 4.0 ± 0 .3 s; p < 0.001) and mean values of CTDIvol and DLP reduced by 46.3% and 47.7%, respectively. Comparing the quality of 70 keV (Group 2) and averaged (Group 1a) images: (a) the mean attenuation within pulmonary arteries did not differ (p = 0.13); (b) the image noise was significantly higher (p < 0.001) in Group 2 with no difference in subjective image noise (p = 0.29); and (c) 89% of examinations were devoid of artifacts in Group 2 vs 28.6% in Group 1a. The percentage of diagnostic examinations was 95.2% (100/105; Group 1a), 100% (53/53; Group 1b), and 95.3% (164/172; Group 2). There were 4.8% (5/105; Group 1a) and 4.7% (8/172; Group 2) of non-diagnostic examinations, mainly due to the suboptimal quality of vascular opacification with the restoration of a diagnostic image quality on low-energy images. CONCLUSION Compared to EID-CT, morphology and perfusion imaging were available in all patients scanned with PCD-CT, with the radiation dose reduced by 48%. CLINICAL RELEVANCE STATEMENT PCD-CT enables scanning patients with the advantages of both spectral imaging, including high-quality morphologic imaging and lung perfusion for all patients, and fast scanning-a combination that is not simultaneously accessible with EID-CT while reducing the radiation dose by almost 50%.
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Affiliation(s)
- Martine Remy-Jardin
- ULR 2694 METRICS Evaluation des technologies de santé et des pratiques médicales, Lille, France.
- IMALLIANCE-Haut-de-France, Valenciennes, France.
- Department of Thoracic Imaging, University of Lille, Lille, France.
| | - Idir Oufriche
- Department of Thoracic Imaging, University of Lille, Lille, France
| | - Lucas Guiffault
- Department of Thoracic Imaging, University of Lille, Lille, France
| | - Alain Duhamel
- ULR 2694 METRICS Evaluation des technologies de santé et des pratiques médicales, Lille, France
- Department of Biostatistics, University of Lille, CHU Lille, Lille, France
| | - Thomas Flohr
- Department of Computed Tomography Research & Development, Siemens Healthineers AG, Forchheim, Germany
| | - Bernhard Schmidt
- Department of Computed Tomography Research & Development, Siemens Healthineers AG, Forchheim, Germany
| | - Jacques Remy
- Department of Thoracic Imaging, University of Lille, Lille, France
- Department of Radiology, Valenciennes Regional Hospital, Valenciennes, France
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Pagkalidou E, Doundoulakis I, Apostolidou-Kiouti F, Bougioukas KI, Papadopoulos K, Tsapas A, Farmakis IT, Antonopoulos AS, Giannakoulas G, Haidich AB. An overview of systematic reviews on imaging tests for diagnosis of pulmonary embolism applying different network meta-analytic methods. Hellenic J Cardiol 2024; 76:88-98. [PMID: 37271191 DOI: 10.1016/j.hjc.2023.05.006] [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: 03/29/2023] [Revised: 05/17/2023] [Accepted: 05/23/2023] [Indexed: 06/06/2023] Open
Abstract
PURPOSE This study aimed to apply different methods of diagnostic test accuracy network meta-analysis (DTA-NMA) for studies reporting results of five imaging tests for the diagnosis of suspected pulmonary embolism (PE): pulmonary angiography (PA), computed tomography angiography (CTPA), magnetic resonance angiography (MRA), planar ventilation/perfusion (V/Q) scintigraphy and single-photon emission computed tomography ventilation/perfusion (SPECT V/Q). METHODS We searched four databases (MEDLINE [via PubMed], Cochrane CENTRAL, Scopus, and Epistemonikos) from inception until June 2, 2022 to identify systematic reviews (SRs) describing diagnostic accuracy of PA, CTPA, MRA, V/Q scan and SPECT V/Q for suspected PE. Study-level data were extracted and pooled using a hierarchical summary receiver operating characteristic (HSROC) meta-regression approach and two DTA-NMA models to compare accuracy estimates of different imaging tests. Risk of bias was assessed using the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies-2) tool and certainty of evidence using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework. RESULTS We identified 13 SRs, synthesizing data from 33 primary studies and for four imaging tests (PA, CTPA, MRA and V/Q scan). The HSROC meta-regression model using PA as the reference standard showed that MRA had the best overall diagnostic performance with sensitivity of 0.93 (95% confidence interval [CI]: 0.76, 1.00) and specificity of 0.94 (95% CI: 0.84, 0.99). However, DTA-NMA models indicated that V/Q scan had the highest sensitivity, while CTPA was most specific. CONCLUSION Selecting a different DTA-NMA method to assess multiple diagnostic tests can affect estimates of diagnostic accuracy. There is no established method, but the choice depends on the data and familiarity with Bayesian statistics.
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Affiliation(s)
- Eirini Pagkalidou
- Department of Hygiene, Social-Preventive Medicine and Medical Statistics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, University Campus, 54124 Thessaloniki, Greece
| | - Ioannis Doundoulakis
- First Department of Cardiology, Hippokration Hospital, National and Kapodistrian University, Athens, Greece
| | - Fani Apostolidou-Kiouti
- Department of Hygiene, Social-Preventive Medicine and Medical Statistics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, University Campus, 54124 Thessaloniki, Greece
| | - Konstantinos I Bougioukas
- Department of Hygiene, Social-Preventive Medicine and Medical Statistics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, University Campus, 54124 Thessaloniki, Greece
| | | | - Apostolos Tsapas
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece; Diabetes Centre, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece; Harris Manchester College, University of Oxford, Oxford, United Kingdom
| | - Ioannis T Farmakis
- Centre for Thrombosis and Haemostasis, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany; First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Alexios S Antonopoulos
- First Department of Cardiology, Hippokration Hospital, National and Kapodistrian University, Athens, Greece
| | - George Giannakoulas
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Anna-Bettina Haidich
- Department of Hygiene, Social-Preventive Medicine and Medical Statistics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, University Campus, 54124 Thessaloniki, Greece.
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Sharma Y, Sumanadasa S, Shahi R, Horwood C, Thompson C. The value of distinguishing patients with isolated subsegmental pulmonary embolism presenting to two tertiary hospitals in Australia: an observational study. J Thromb Thrombolysis 2023:10.1007/s11239-023-02845-3. [PMID: 37335459 DOI: 10.1007/s11239-023-02845-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/03/2023] [Indexed: 06/21/2023]
Abstract
Isolated-subsegmental-pulmonary-embolism (SSPE) is increasingly diagnosed with the use of computed-tomography-pulmonary-angiogram (CTPA). There remains clinical equipoise for management of SSPE with previous studies not accounting for frailty while determining clinical outcomes. Clinical outcomes among patients with isolated SSPE were compared with those with a more proximal PE after accounting for frailty and other risk-factors. This study included all patients with a positive CTPA for pulmonary embolism (PE) admitted between 2017 and 2021 to two Australian-tertiary-hospitals. Frailty was determined by use of the hospital-frailty-risk-score (HFRS). Competing-risk-analysis and Cox-proportional hazard models determined the cumulative-risk of VTE and mortality within 3 months and 1 year of index PE event after adjustment for frailty and other variables. Of 334 patients with positive CTPA for PE, 111 (33.2%) had isolated-SSPE. The mean (SD) age was 64.3 (17.7) years, 50.9% were males and 9.6% were frail. The risk of recurrent VTE within 3-months (0.9% vs. 1.8%, P = 0.458) and within 1-year of follow-up (2.7% vs. 6.3%, P = 0.126) did not differ significantly between patients with isolated SSPE and those with more proximal PE. After adjusted analyses, the cumulative-incidence of recurrent VTE was not different among patients with isolated SSPE within 1 year of index event [subdistribution-hazard-ratio (HR) 0.84, 95% CI 0.19 to 3.60]. Similarly, mortality within 1 year of index event was also not different between the two groups (aHR 1.72, 95% CI 0.92-3.23). The prevalence of SSPE was 33.2% and even after adjustment for frailty these patients had no different clinical outcomes than those with proximal PE.
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Affiliation(s)
- Yogesh Sharma
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia.
- Department of General Medicine, Division of Medicine, Cardiac & Critical Care, Flinders Medical Centre, Flinders Drive, Bedford Park, Adelaide, SA, 5002, Australia.
| | - Subodha Sumanadasa
- Department of General Medicine, Division of Medicine, Cardiac & Critical Care, Flinders Medical Centre, Flinders Drive, Bedford Park, Adelaide, SA, 5002, Australia
| | - Rashmi Shahi
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Chris Horwood
- Department of Clinical Epidemiology, Flinders Medical Centre, Adelaide, SA, Australia
| | - Campbell Thompson
- Discipline of Medicine, The University of Adelaide, Adelaide, SA, Australia
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Clinical Significance and Outcome in Patients with Asymptomatic Versus Symptomatic Subsegmental Pulmonary Embolism. J Clin Med 2023; 12:jcm12041640. [PMID: 36836176 PMCID: PMC9959177 DOI: 10.3390/jcm12041640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 02/10/2023] [Accepted: 02/15/2023] [Indexed: 02/22/2023] Open
Abstract
The clinical significance and optimal therapy of patients with subsegmental pulmonary embolism (SSPE) remain controversial. We used the data in the RIETE Registry to compare the baseline characteristics, treatment, and outcomes during anticoagulation and after its discontinuation in patients with asymptomatic vs. symptomatic SSPE. From January 2009 to September 2022, there were 2135 patients with a first episode of SSPE, of whom 160 (7.5%) were asymptomatic. Most patients in both subgroups received anticoagulant therapy (97% vs. 99.4%, respectively). During anticoagulation, 14 patients developed symptomatic pulmonary embolism (PE) recurrences, 28 lower-limb deep vein thrombosis (DVT), 54 bled, and 242 died. The patients with asymptomatic SSPE had similar rates of symptomatic PE recurrences (hazard ratio (HR): 2.46; 95% CI: 0.37-9.74), DVT (HR: 0.53; 95% CI: 0.03-2.80), or major bleeding (HR: 0.85; 95% CI: 0.21-2.42) to those with symptomatic SSPE, but had a higher mortality rate (HR: 1.59; 95% CI: 1.25-2.94). The rate of major bleeding outweighed the rate of PE recurrences (54 major bleeds vs. 14 PE recurrences), and the rate of fatal bleeds outweighed the rate of fatal PE recurrences (12 vs. 6 deaths). After discontinuing anticoagulation, the patients with asymptomatic SSPE had a similar rate of PE recurrences (HR: 1.27; 95% CI: 0.20-4.55) and a non-significantly higher mortality rate (HR: 2.06; 95% CI: 0.92-4.10). The patients with asymptomatic SSPE had similar rates of PE recurrences to those with symptomatic SSPE, during and after discontinuing anticoagulation. The unexpectedly higher rate of major bleeding than recurrences highlights the need for randomized trials to find the best management.
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Alenezi F, Covington TA, Mukherjee M, Mathai SC, Yu PB, Rajagopal S. Novel Approaches to Imaging the Pulmonary Vasculature and Right Heart. Circ Res 2022; 130:1445-1465. [PMID: 35482838 PMCID: PMC9060389 DOI: 10.1161/circresaha.121.319990] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
There is an increased appreciation for the importance of the right heart and pulmonary circulation in several disease states across the spectrum of pulmonary hypertension and left heart failure. However, assessment of the structure and function of the right heart and pulmonary circulation can be challenging, due to the complex geometry of the right ventricle, comorbid pulmonary airways and parenchymal disease, and the overlap of hemodynamic abnormalities with left heart failure. Several new and evolving imaging modalities interrogate the right heart and pulmonary circulation with greater diagnostic precision. Echocardiographic approaches such as speckle-tracking and 3-dimensional imaging provide detailed assessments of regional systolic and diastolic function and volumetric assessments. Magnetic resonance approaches can provide high-resolution views of cardiac structure/function, tissue characterization, and perfusion through the pulmonary vasculature. Molecular imaging with positron emission tomography allows an assessment of specific pathobiologically relevant targets in the right heart and pulmonary circulation. Machine learning analysis of high-resolution computed tomographic lung scans permits quantitative morphometry of the lung circulation without intravenous contrast. Inhaled magnetic resonance imaging probes, such as hyperpolarized 129Xe magnetic resonance imaging, report on pulmonary gas exchange and pulmonary capillary hemodynamics. These approaches provide important information on right ventricular structure and function along with perfusion through the pulmonary circulation. At this time, the majority of these developing technologies have yet to be clinically validated, with few studies demonstrating the utility of these imaging biomarkers for diagnosis or monitoring disease. These technologies hold promise for earlier diagnosis and noninvasive monitoring of right heart failure and pulmonary hypertension that will aid in preclinical studies, enhance patient selection and provide surrogate end points in clinical trials, and ultimately improve bedside care.
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Affiliation(s)
- Fawaz Alenezi
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC
| | | | | | - Steve C. Mathai
- Johns Hopkins Division of Pulmonary and Critical Care Medicine, Baltimore, MD
| | - Paul B. Yu
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA
| | - Sudarshan Rajagopal
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC
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Le Gal G, Kovacs MJ, Bertoletti L, Couturaud F, Dennie C, Hirsch AM, Huisman MV, Klok FA, Kraaijpoel N, Mallick R, Pecarskie A, Pena E, Phillips P, Pichon I, Ramsay T, Righini M, Rodger MA, Roy PM, Sanchez O, Schmidt J, Schulman S, Shivakumar S, Trinh-Duc A, Verdet R, Vinsonneau U, Wells P, Wu C, Yeo E, Carrier M. Risk for Recurrent Venous Thromboembolism in Patients With Subsegmental Pulmonary Embolism Managed Without Anticoagulation : A Multicenter Prospective Cohort Study. Ann Intern Med 2022; 175:29-35. [PMID: 34807722 DOI: 10.7326/m21-2981] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The incidence of pulmonary embolism has been increasing, but its case-fatality rate is decreasing, suggesting a lesser severity of illness. The clinical importance of patients with pulmonary embolism isolated to the subsegmental vessels is unknown. OBJECTIVE To determine the rate of recurrent venous thromboembolism in patients with subsegmental pulmonary embolism managed without anticoagulation. DESIGN Multicenter prospective cohort study. (ClinicalTrials.gov: NCT01455818). SETTING Eighteen sites between February 2011 and February 2021. PATIENTS Patients with isolated subsegmental pulmonary embolism. INTERVENTION At diagnosis, patients underwent bilateral lower-extremity venous ultrasonography, which was repeated 1 week later if results were negative. Patients without deep venous thrombosis did not receive anticoagulant therapy. MEASUREMENTS The primary outcome was recurrent venous thromboembolism during the 90-day follow-up period. RESULTS Recruitment was stopped prematurely because the predefined stopping rule was met after 292 of a projected 300 patients were enrolled. Of the 266 patients included in the primary analysis, the primary outcome occurred in 8 patients, for a cumulative incidence of 3.1% (95% CI, 1.6% to 6.1%) over the 90-day follow-up. The incidence of recurrent venous thromboembolism was 2.1% (CI, 0.8% to 5.5%) and 5.7% (CI, 2.2% to 14.4%) over the 90-day follow-up in patients with single and multiple isolated subsegmental pulmonary embolism, respectively. No patients had a fatal recurrent pulmonary embolism. LIMITATION The study was restricted to patients with low-risk subsegmental pulmonary embolism. CONCLUSION Overall, patients with subsegmental pulmonary embolism who did not have proximal deep venous thrombosis had a higher-than-expected rate of recurrent venous thromboembolism. PRIMARY FUNDING SOURCE Heart and Stroke Foundation of Canada and French Ministry of Health Programme Hospitalier de Recherche Clinique.
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Affiliation(s)
- Grégoire Le Gal
- Centre d'Investigation Clinique, Centre Hospitalier Régional et Universitaire de Brest, Brest, France, and Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (G.L.)
| | - Michael J Kovacs
- Division of Hematology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada (M.J.K.)
| | - Laurent Bertoletti
- Service de Médecine Vasculaire et Thérapeutique, Hôpital Nord, CHU de St-Etienne, INSERM, SAINBIOSE, U1059, Dysfonction Vasculaire et Hémostase et Université Jean-Monnet, CIC1408, F- 42055 Saint-Etienne, Réseau français F-CRIN INNOVTE, Saint-Etienne, France (L.B.)
| | - Francis Couturaud
- Centre d'Investigation Clinique, Centre Hospitalier Régional et Universitaire de Brest, and Département de médecine interne, médecine vasculaire et pneumologie, Hôpital de la Cavale Blanche, EA3878-GETBO, Univ Brest, Réseau français F-CRIN INNOVTE, CHRU Brest, Brest, France (F.C.)
| | - Carole Dennie
- Department of Radiology, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (C.D., E.P.)
| | - Andrew M Hirsch
- Department of Medicine, McGill University, Jewish General Hospital, Montreal, Quebec, Canada (A.M.H.)
| | - Menno V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Dutch Thrombosis Network, Leiden, the Netherlands (M.V.H., F.A.K.)
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Dutch Thrombosis Network, Leiden, the Netherlands (M.V.H., F.A.K.)
| | - Noémie Kraaijpoel
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands (N.K.)
| | - Ranjeeta Mallick
- Ottawa Methods Center, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (R.M.)
| | - Amanda Pecarskie
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (A.P., P.P., P.W., M.C.)
| | - Elena Pena
- Department of Radiology, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (C.D., E.P.)
| | - Penny Phillips
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (A.P., P.P., P.W., M.C.)
| | - Isabelle Pichon
- Service de Recherche Clinique, Hôpital d'Instruction des Armées, Brest, France (I.P.)
| | - Tim Ramsay
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (T.R.)
| | - Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland (M.R.)
| | - Marc A Rodger
- Department of Medicine, McGill University, McGill University Health Center, Montreal, Quebec, Canada (M.A.R.)
| | - Pierre-Marie Roy
- Univ Angers, MITOVASC, Equipe CarMe, Département de Médecine d'Urgence, Centre Hospitalier Universitaire d'Angers, Réseau français F-CRIN INNOVTE, Angers, France (P.R.)
| | - Olivier Sanchez
- Université de Paris, Service de Pneumologie et Soins Intensifs, Hôpital Européen Georges Pompidou, AP-HP.Centre - Université de Paris, INSERM UMR S 1140 Innovative therapies in hemostasis, Réseau français F-CRIN INNOVTE, Paris, France (O.S.)
| | - Jeannot Schmidt
- Département de Médecine d'Urgence, Centre Hospitalier Universitaire Gabriel Montpied, Réseau français F-CRIN INNOVTE, Clermont-Ferrand, France (J.S.)
| | - Sam Schulman
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada, and Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia (S.S.)
| | - Sudeep Shivakumar
- Department of Medicine, Dalhousie University, Nova Scotia Health, Halifax, Nova Scotia, Canada (S.S.)
| | | | - Rachel Verdet
- Direction de la Recherche et de l'Innovation, Centre Hospitalier Régional Universitaire de Brest, Brest, France (R.V.)
| | - Ulric Vinsonneau
- Department of Cardiology, Clermont Tonnerre Hospital of Military Training, Brest, France (U.V.)
| | - Philip Wells
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (A.P., P.P., P.W., M.C.)
| | - Cynthia Wu
- Department of Medicine, University of Alberta Hospital, Edmonton, Alberta, Canada (C.W.)
| | - Erik Yeo
- Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada (E.Y.)
| | - Marc Carrier
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (A.P., P.P., P.W., M.C.)
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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.
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Fathala A, Aldurabi A. Frequency of computed tomography abnormalities in patients with chronic thromboembolic pulmonary hypertension: a comparative study between lung perfusion scan and computed tomography pulmonary angiography. Multidiscip Respir Med 2021; 16:753. [PMID: 34322231 PMCID: PMC8273626 DOI: 10.4081/mrm.2021.753] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 05/31/2021] [Indexed: 12/12/2022] Open
Abstract
Introduction Chronic thromboembolic pulmonary hypertension (CTEPH) is one of the leading causes of pulmonary hypertension. Diagnosis of CTEPH can be established using various imaging techniques, including ventilation-perfusion scintigraphy (VQ) and multidetector computed tomography pulmonary angiography (CTPA). The aim of this study was to determine the frequency of direct pulmonary vascular, parenchymal lung, and cardiac abnormalities on CTPA in patients with CTEPH and to compare the diagnostic accuracy of both VQ scan CTPA in detecting CTEPH. Methods We retrospectively included 54 patients who had been referred for pulmonary hypertension service (20 males, 34 females). All patients had VQ scan and CTPA within 15 days and underwent pulmonary artery endarterectomy (PEA) thereafter. VQ scans were reported according to modified PIOPED (Prospective Investigation of Pulmonary Embolism Diagnosis) criteria. CTPA was considered as diagnostic for CTEPH if it showed presence of thrombus, webs, stenosis, or perfusion lung abnormalities. Results The mean age of the study population was 41±10 years. The mean pulmonary artery pressure was 53±13 mmHg. Fifty-three out of 54 patients in the study population had high probability VQ scan and one patient had intermediate probability. CTPA was suggestive of CTEPH in all patients. The most frequent CTPA findings in the central pulmonary arteries and peripheral arteries were presence of thrombotic materials, abnormal vessel tapering and abrupt vessels-cut off (76% vs 65%, 67% vs 48%, and 48% vs 22%), respectively. The mosaic lung perfusion was present in 78% of the patients, and various cardiac morphology abnormalities were present and most common was abnormal right to left ventricle ratio (69%). Conclusion Our findings indicate that both VQ scan and CTPA are highly sensitive for the detection of CTEPH confirmed by PEA. Most CTEPH patients had several pulmonary vascular, parenchymal lung and cardiac abnormalities. There was no sign with 100% sensitivity on CTPA for CTEPH detection.
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Affiliation(s)
- Ahmed Fathala
- Department of Radiology, Nuclear Medicine and Cardiovascular Imaging, King Faisal Specialist Hospital and Research Center, Riyadh
| | - Alaa Aldurabi
- Department of Radiology, College of Medicine, Qassim University, Buraidah, Saudi Arabia
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Zhou C, Chan HP, Chughtai A, Patel S, Kuriakose J, Hadjiiski LM, Wei J, Kazerooni EA. Variabilities in Reference Standard by Radiologists and Performance Assessment in Detection of Pulmonary Embolism in CT Pulmonary Angiography. J Digit Imaging 2021; 32:1089-1096. [PMID: 31073815 DOI: 10.1007/s10278-019-00228-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Annotating lesion locations by radiologists' manual marking is a key step to provide reference standard for the training and testing of a computer-aided detection system by supervised machine learning. Inter-reader variability is not uncommon in readings even by expert radiologists. This study evaluated the variability of the radiologist-identified pulmonary emboli (PEs) to demonstrate the importance of improving the reliability of the reference standard by a multi-step process for performance evaluation. In an initial reading of 40 CTPA PE cases, two experienced thoracic radiologists independently marked the PE locations. For markings from the two radiologists that did not agree, each radiologist re-read the cases independently to assess the discordant markings. Finally, for markings that still disagreed after the second reading, the two radiologists read together to reach a consensus. The variability of radiologists was evaluated by analyzing the agreement between two radiologists. For the 40 cases, 475 and 514 PEs were identified by radiologists R1 and R2 in the initial independent readings, respectively. For a total of 545 marks by the two radiologists, 81.5% (444/545) of the marks agreed but 101 marks in 36 cases differed. After consensus, 65 (64.4%) and 36 (35.6%) of the 101 marks were determined to be true PEs and false positives (FPs), respectively. Of these, 48 and 17 were false negatives (FNs) and 14 and 22 were FPs by R1 and R2, respectively. Our study demonstrated that there is substantial variability in reference standards provided by radiologists, which impacts the performance assessment of a lesion detection system. Combination of multiple radiologists' readings and consensus is needed to improve the reliability of a reference standard.
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Affiliation(s)
- Chuan Zhou
- Department of Radiology, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA.
| | - Heang-Ping Chan
- Department of Radiology, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Aamer Chughtai
- Department of Radiology, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Smita Patel
- Department of Radiology, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Jean Kuriakose
- Department of Radiology, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Lubomir M Hadjiiski
- Department of Radiology, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Jun Wei
- Department of Radiology, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Ella A Kazerooni
- Department of Radiology, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
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Lyman GH, Carrier M, Ay C, Di Nisio M, Hicks LK, Khorana AA, Leavitt AD, Lee AYY, Macbeth F, Morgan RL, Noble S, Sexton EA, Stenehjem D, Wiercioch W, Kahale LA, Alonso-Coello P. American Society of Hematology 2021 guidelines for management of venous thromboembolism: prevention and treatment in patients with cancer. Blood Adv 2021; 5:927-974. [PMID: 33570602 PMCID: PMC7903232 DOI: 10.1182/bloodadvances.2020003442] [Citation(s) in RCA: 384] [Impact Index Per Article: 128.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 10/29/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a common complication among patients with cancer. Patients with cancer and VTE are at a markedly increased risk for morbidity and mortality. OBJECTIVE These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in their decisions about the prevention and treatment of VTE in patients with cancer. METHODS ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The guideline development process was supported by updated or new systematic evidence reviews. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to assess evidence and make recommendations. RESULTS Recommendations address mechanical and pharmacological prophylaxis in hospitalized medical patients with cancer, those undergoing a surgical procedure, and ambulatory patients receiving cancer chemotherapy. The recommendations also address the use of anticoagulation for the initial, short-term, and long-term treatment of VTE in patients with cancer. CONCLUSIONS Strong recommendations include not using thromboprophylaxis in ambulatory patients receiving cancer chemotherapy at low risk of VTE and to use low-molecular-weight heparin (LMWH) for initial treatment of VTE in patients with cancer. Conditional recommendations include using thromboprophylaxis in hospitalized medical patients with cancer, LMWH or fondaparinux for surgical patients with cancer, LMWH or direct oral anticoagulants (DOAC) in ambulatory patients with cancer receiving systemic therapy at high risk of VTE and LMWH or DOAC for initial treatment of VTE, DOAC for the short-term treatment of VTE, and LMWH or DOAC for the long-term treatment of VTE in patients with cancer.
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Affiliation(s)
- Gary H Lyman
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA
- Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, ON, Canada
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Marcello Di Nisio
- Department of Medicine and Aging Sciences, University G. D'Annunzio, Chieti, Italy
| | - Lisa K Hicks
- Division of Hematology/Oncology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Alok A Khorana
- Cleveland Clinic and Case Comprehensive Cancer Center, Cleveland, OH
| | - Andrew D Leavitt
- Department of Laboratory Medicine and
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Agnes Y Y Lee
- Division of Hematology, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Division of Medical Oncology, BC Cancer, Vancouver site, Provincial Health Services Authority, Vancouver, BC, Canada
| | | | - Rebecca L Morgan
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Simon Noble
- Division of Population Medicine, Cardiff University School of Medicine, Cardiff, United Kingdom
| | | | | | - Wojtek Wiercioch
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Lara A Kahale
- American University of Beirut (AUB) Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Center, American University of Beirut, Beirut, Lebanon; and
| | - Pablo Alonso-Coello
- Cochrane Iberoamérica, Biomedical Research Institute Sant Pau-CIBERESP, Barcelona, Spain
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11
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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: 4] [Impact Index Per Article: 1.3] [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.
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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
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12
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Baumgartner C, Klok FA, Carrier M, Limacher A, Moor J, Righini M, Beer JH, Peluso M, Rakovic D, Huisman MV, Aujesky D. Clinical Surveillance vs. Anticoagulation For low-risk patiEnts with isolated SubSegmental Pulmonary Embolism: protocol for a multicentre randomised placebo-controlled non-inferiority trial (SAFE-SSPE). BMJ Open 2020; 10:e040151. [PMID: 33444199 PMCID: PMC7678381 DOI: 10.1136/bmjopen-2020-040151] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION The clinical significance of subsegmental pulmonary embolism (SSPE) is currently unclear. Although growing evidence from observational studies suggests that withholding anticoagulant treatment may be a safe option in selected patients with isolated SSPE, most patients with this condition receive anticoagulant treatment, which is associated with a 90-day risk of recurrent venous thromboembolism (VTE) of 0.8% and major bleeding of up to 5%. Given the ongoing controversy concerning the risk-benefit ratio of anticoagulation for isolated SSPE and the lack of evidence from randomised-controlled studies, the aim of this clinical trial is to evaluate the efficacy and safety of clinical surveillance without anticoagulation in low-risk patients with isolated SSPE. METHODS AND ANALYSIS SAFE-SSPE (Surveillance vs. Anticoagulation For low-risk patiEnts with isolated SubSegmental Pulmonary Embolism, a multicentre randomised placebo-controlled non-inferiority trial) is an international, multicentre, placebo-controlled, double-blind, parallel-group non-inferiority trial conducted in Switzerland, the Netherlands and Canada. Low-risk patients with isolated SSPE are randomised to receive clinical surveillance with either placebo (no anticoagulation) or anticoagulant treatment with rivaroxaban. All patients undergo bilateral whole-leg compression ultrasonography to exclude concomitant deep vein thrombosis before enrolment. Patients are followed for 90 days. The primary outcome is symptomatic recurrent VTE (efficacy). The secondary outcomes include clinically significant bleeding and all-cause mortality (safety). The ancillary outcomes are health-related quality of life, functional status and medical resource utilisation. ETHICS AND DISSEMINATION The local ethics committees in Switzerland have approved this protocol. Submission to the Ethical Committees in the Netherlands and Canada is underway. The results of this trial will be published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT04263038.
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Affiliation(s)
- Christine Baumgartner
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Marc Carrier
- Department of Medicine, The Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Ontario, Canada
| | | | - Jeanne Moor
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marc Righini
- Division of Angiology and Haemostasis, Geneva University Hospital, University of Geneva, Geneva, Switzerland
| | - Jürg-Hans Beer
- Department of Internal Medicine, Cantonal Hospital of Baden, Baden, Switzerland
| | - Martina Peluso
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Damiana Rakovic
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Roberge G, Delluc A. Challenging anticoagulation cases: A case of incidental subsegmental pulmonary embolism in a patient with cancer. Thromb Res 2020; 197:77-83. [PMID: 33190023 DOI: 10.1016/j.thromres.2020.10.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 10/27/2020] [Accepted: 10/29/2020] [Indexed: 02/07/2023]
Abstract
Cancer therapy and progress in quality of imaging technologies for cancer surveillance and staging are in cause for the increase incidence of smaller incidental pulmonary embolism (PE). The clinical significance of incidental subsegmental pulmonary embolism (SSPE) is hard to define, balancing between possible false positive result, hypercoagulability signal, and truly venous thromboembolism (VTE) event. Evidence for optimal management of such findings are largely extrapolated from symptomatic SSPE in non-cancer patients and from symptomatic, more proximal PE in cancer patients. Current practice guidelines vary but some suggest withholding anticoagulation in selected patients. However, most SSPEs, incidental or not, should be treated as any other cancer-associated PE due to likely similar prognosis. Choice and duration of anticoagulation are extended from existing knowledge on more proximal PE.
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Affiliation(s)
- Guillaume Roberge
- Department of General Internal Medicine, Centre Hospitalier Universitaire de Québec, Hôpital St-François d'Assise, Université Laval, Québec, Canada
| | - Aurélien Delluc
- Department of Medicine and the Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada.
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14
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Dalia T, Ranka S, Patel N, Lippmann M, Pierpoline M, Robinson A, Hacker E, Isom N, Buechler T, Mabry T, Janish C, Satterwhite L, Gupta K. Clinical presentation and outcomes of patients with isolated subsegmental pulmonary embolism: A tertiary care center experience. Vasc Med 2020; 25:468-470. [PMID: 32558627 DOI: 10.1177/1358863x20930279] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Tarun Dalia
- Department of Cardiovascular Medicine, The University of Kansas Health System, Kansas City, KS, USA
| | - Sagar Ranka
- Department of Cardiovascular Medicine, The University of Kansas Health System, Kansas City, KS, USA
| | - Nilay Patel
- Department of Cardiovascular Medicine, The University of Kansas Health System, Kansas City, KS, USA
| | - Matthew Lippmann
- Department of Cardiovascular Medicine, The University of Kansas Health System, Kansas City, KS, USA
| | - Michael Pierpoline
- Department of Cardiovascular Medicine, The University of Kansas Health System, Kansas City, KS, USA
| | - Alexander Robinson
- Department of Internal Medicine, The University of Kansas Health System, Kansas City, KS, USA
| | - Ethan Hacker
- Department of Internal Medicine, The University of Kansas Health System, Kansas City, KS, USA
| | - Nicholas Isom
- Department of Internal Medicine, The University of Kansas Health System, Kansas City, KS, USA
| | - Tyler Buechler
- Department of Internal Medicine, The University of Kansas Health System, Kansas City, KS, USA
| | - Terrance Mabry
- Medical Student, The University of Kansas Health System, Kansas City, KS, USA
| | - Christopher Janish
- Department of Cardiovascular Medicine, Krannert Institute of Cardiology, Indiana University, Indianapolis, IN, USA
| | - Lewis Satterwhite
- Department of Pulmonary and Critical Care Medicine, The University of Kansas Health System, Kansas City, KS, USA
| | - Kamal Gupta
- Department of Cardiovascular Medicine, The University of Kansas Health System, Kansas City, KS, USA
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15
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Adverse Events and Mortality in Anticoagulated Patients with Different Categories of Pulmonary Embolism. Mayo Clin Proc Innov Qual Outcomes 2020; 4:249-258. [PMID: 32542216 PMCID: PMC7283932 DOI: 10.1016/j.mayocpiqo.2020.02.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Objective To determine whether the pulmonary embolism (PE) categories of massive, submassive, PE with no right ventricle dysfunction (NRVD), and subsegmental only (SSO) adequately predict clinical outcome. Methods Patients treated for acute PE (March 1, 2013, through July 31, 2019) were followed forward prospectively to compare venous thromboembolism (VTE) recurrence, all-cause mortality, major bleeding, and clinically relevant nonmajor bleeding (CRNMB) across 4 PE categories. Results Of 2703 patients with VTE, 1188 (44%) had PE, of which 1021 (85.9%) completed at least 3 months of therapy or had clinical outcomes precluding further treatment (27 with massive, 217 submassive, 557 NRVD, and 220 SSO PE). One patient with massive, 8 with submassive, 23 with NRVD, and 5 with SSO PE had recurrent VTE (3.90, 5.33, 5.36, and 3.66 per 100 person-years, respectively; P=.84). There were 3 deaths in massive, 27 in submassive, 140 in NRVD, and 34 in SSO PE groups (11.59, 17.37, 31.74, and 24.74 per 100 person-years, respectively; P=.02); when adjusted for cancer, the relationship was no longer significant (P=.27). One patient with massive, 5 with submassive, 22 with NRVD, and 5 with SSO PE had major bleeding (3.90, 3.31, 5.24, and 3.75 per 100 person-years, respectively; P=.66). Similar cumulative rates for CRNMB were observed (P=.87). Three-month rates of VTE recurrence, death, major bleeding, and CRNMB did not differ by PE category. Conclusion In the setting of anticoagulation therapy with maximal standardization and evidence-based practice, there is no evidence of a difference between PE categories and outcomes. Trial Registration clinicaltrials.gov Identifier: NCT03504007.
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Key Words
- AHA, American Heart Association
- CRNMB, clinically relevant nonmajor bleeding
- CT, computed tomography
- DVT, deep vein thrombosis
- HR, hazard ratio
- NRVD, no right ventricle dysfunction
- PE, pulmonary embolism
- PESI, Pulmonary Embolism Severity Index
- RV, right ventricle
- SSO, subsegmental only
- VTE, venous thromboembolism
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16
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Yoo HHB, Nunes‐Nogueira VS, Fortes Villas Boas PJ. Anticoagulant treatment for subsegmental pulmonary embolism. Cochrane Database Syst Rev 2020; 2:CD010222. [PMID: 32030721 PMCID: PMC7004894 DOI: 10.1002/14651858.cd010222.pub4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Acute pulmonary embolism (PE) is a common cause of death, accounting for 50,000 to 200,000 deaths annually. It is the third most common cause of mortality among the cardiovascular diseases, after coronary artery disease and stroke. The advent of multi-detector computed tomographic pulmonary angiography (CTPA) has allowed better assessment of PE regarding visualisation of the peripheral pulmonary arteries, increasing its rate of diagnosis. More cases of peripheral PEs, such as isolated subsegmental PE (SSPE) and incidental PE, have thereby been identified. These two conditions are usually found in patients with few or none of the classic PE symptoms such as haemoptysis or pleuritic pain, acute dyspnoea or circulatory collapse. However, in patients with reduced cardiopulmonary reserve, classic PE symptoms can be found with isolated SSPEs. Incidental SSPE is found casually in asymptomatic patients, usually by diagnostic imaging performed for other reasons (for example routine CT for cancer staging in oncology patients). Traditionally, all PEs are anticoagulated in a similar manner independent of their location, or number and size of the thrombi. It has been suggested that many patients with SSPE may be treated without benefit, increasing adverse events by a possible unnecessary use of anticoagulants. Patients with isolated SSPE, or incidental PE, may have a more benign clinical presentation compared to those with proximal PEs. However, the clinical significance in patients, and their prognosis, needs to be studied to evaluate whether anticoagulation therapy is required. This is the second update of the Cochrane systematic review published in 2014. OBJECTIVES To assess the effectiveness and safety of anticoagulation therapy versus control in patients with isolated subsegmental pulmonary embolism (SSPE) or incidental SSPE. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and AMED databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 26 November 2019. We also undertook reference checking to identify additional studies. SELECTION CRITERIA We included randomised controlled trials of anticoagulation therapy versus control in patients with SSPE or incidental SSPE. DATA COLLECTION AND ANALYSIS Two review authors inspected all citations identified to ensure reliable assessment. If relevant studies were identified, we planned for two review authors to independently extract data and to assess the methodological quality of identified trials using the criteria recommended in the Cochrane Handbook for Systematic Reviews of Interventions. MAIN RESULTS We did not identify any studies that met the inclusion criteria. AUTHORS' CONCLUSIONS There is no evidence from randomised controlled trials to assess the effectiveness and safety of anticoagulation therapy versus control in patients with isolated subsegmental pulmonary embolism (SSPE) or incidental SSPE. Well-conducted research is required before informed practice decisions can be made.
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Affiliation(s)
- Hugo HB Yoo
- Botucatu Medical School, São Paulo State University‐UNESPDepartment of Internal MedicineBotucatuSão PauloBrazil18618‐687
| | - Vania Santos Nunes‐Nogueira
- Botucatu Medical School, São Paulo State University‐UNESPDepartment of Internal MedicineBotucatuSão PauloBrazil18618‐687
| | - Paulo J Fortes Villas Boas
- Botucatu Medical School, São Paulo State University‐UNESPDepartment of Internal MedicineBotucatuSão PauloBrazil18618‐687
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Holstensson M, Smedby Ö, Poludniowski G, Sanchez-Crespo A, Savitcheva I, Öberg M, Grybäck P, Gabrielson S, Sandqvist P, Bartholdson E, Axelsson R. Comparison of acquisition protocols for ventilation/perfusion SPECT-a Monte Carlo study. Phys Med Biol 2019; 64:235018. [PMID: 31362272 DOI: 10.1088/1361-6560/ab36ee] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
One of the most commonly used imaging techniques for diagnosing pulmonary embolism (PE) is ventilation/perfusion (V/P) scintigraphy. The aim of this study was to evaluate the performance of the currently used imaging protocols for V/P single photon emission computed tomography (V/P SPECT) at two nuclear medicine department sites and to investigate the effect of altering important protocol parameters. The Monte Carlo technique was used to simulate 4D digital phantoms with perfusion defects. Six imaging protocols were included in the study and a total of 72 digital patients were simulated. Six dually trained radiologists/nuclear medicine physicians reviewed the images and reported all perfusion mismatch findings. The radiologists also visually graded the image quality. No statistically significant differences in diagnostic performance were found between the studied protocols, but visual grading analysis pointed out one protocol as significantly superior to four of the other protocols. Considering the study results, we have decided to harmonize our clinical protocols for imaging patients with suspected PE. The administered Technegas and macro aggregated albumin activities have been altered, a low energy all purpose collimator is used instead of a low energy high resolution collimator and the acquisition times have been lowered.
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Affiliation(s)
- Maria Holstensson
- Medical Radiation Physics and Nuclear Medicine, Imaging and Physiology, Karolinska University Hospital, Stockholm, Sweden. Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Functional Imaging and Technology, Karolinska Institutet, Stockholm, Sweden. Author to whom any corrrespondence should be addressed
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18
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Stoller N, Limacher A, Méan M, Baumgartner C, Tritschler T, Righini M, Beer JH, Rodondi N, Aujesky D. Clinical presentation and outcomes in elderly patients with symptomatic isolated subsegmental pulmonary embolism. Thromb Res 2019; 184:24-30. [PMID: 31683107 DOI: 10.1016/j.thromres.2019.10.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 10/05/2019] [Accepted: 10/14/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Data are limited on clinical presentation and outcomes in elderly patients with acute symptomatic isolated subsegmental pulmonary embolism (SSPE). We compared clinical presentation, risk factors, processes of care, and outcomes between elderly patients with SSPE and patients with more proximal pulmonary embolism (PE). METHODS We prospectively followed 578 patients aged ≥65 years with acute symptomatic isolated SSPE or proximal PE in a multicentre Swiss cohort study. We compared quality of life at three months using the PEmb-QoL, and examined the independent association between localization of PE and clinical outcomes (recurrent venous thromboembolism [VTE], overall mortality) using regression models with adjustment for potential confounders. RESULTS Overall, 11% of patients had isolated SSPE. Patients with SSPE were less likely to have a pulse ≥110/min (3% vs. 13%), but more likely to have active cancer (28% vs. 15%) and to receive outpatient care (11% vs. 4%) than patients with proximal PE. Virtually all patients (98%) with SSPE received anticoagulants. Quality of life did not differ between the groups at 3 months. No patient with SSPE vs. seven patients with proximal PE died from the index PE event. No significant difference was observed for the 3-year cumulative incidence of recurrent VTE (7% vs. 12%) and death (29% vs. 20%). After adjustment, SSPE was not associated with a lower risk of clinical outcomes than proximal PE. CONCLUSIONS Clinical presentation and incidences of adverse outcomes did not differ significantly between elderly patients with SSPE or proximal PE, although the power to detect differences might have been limited given the small number of events. Thus, our study does not provide evidence that unselected, elderly patients with SSPE have a more benign clinical course.
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Affiliation(s)
- Nina Stoller
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Andreas Limacher
- Clinical Trials Unit Bern, University of Bern, Bern, Switzerland
| | - Marie Méan
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Division of Internal Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - 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
| | - Marc Righini
- Division of Angiology and Haemostasis, Geneva University Hospital, Geneva, Switzerland
| | - Jürg-Hans Beer
- Department of Internal Medicine, Cantonal Hospital of Baden, Baden, Switzerland
| | - Nicolas Rodondi
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Radiologist Performance in the Detection of Pulmonary Embolism: Features that Favor Correct Interpretation and Risk Factors for Errors. J Thorac Imaging 2019; 33:350-357. [PMID: 30142136 DOI: 10.1097/rti.0000000000000361] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE This study aimed to assess the factors contributing toward accurate detection and erroneous interpretation of pulmonary embolism (PE). MATERIALS AND METHODS Over 13 months, all computed tomography pulmonary angiography studies were retrospectively rereviewed by a chest radiologist. Two additional chest radiologists assessed cases with disagreement between the first interpretation and rereview. The number, extent, and location of PE and specialty training, experience, time of study, kV, resident prelim, use of iterative reconstruction, signal to noise ratio (SNR), and reports describing the study as "limited" were recorded. Parametric and nonparametric statistical testing was performed (significance P<0.05). RESULTS Of 2555 computed tomography pulmonary angiography cases assessed, there were 230 true positive (170 multiple, 60 single PE), 2271 true negative, 35 false-negative (15 multiple and 20 single PE), and 19 false-positive studies. The overall sensitivity, specificity, positive predictive value, negative predictive value and accuracy of radiologists was 86.8%, 99.2%, 92.4%, 98.5%, and 97.9%. Sensitivity for the detection of multiple and central PE was significantly higher than the detection of single and peripheral PE, respectively (P<0.01 for both). The sensitivity of thoracic radiologists (91.7%) was higher than nonthoracic (82.8%) and reached significance for single PE (89.2% vs. 61.4%, P<0.02). Errors were more likely in cases with lower SNR (P=0.04) and those described as limited (P<0.001). Misses occurred more frequently in the upper lobe posterior and lower lobe lateral segments and subsegments (P=0.038). CONCLUSIONS The accuracy for PE detection is high, but errors are more likely in studies with single PE interpreted by nonthoracic radiologists, especially when located in certain segments and in cases with low SNR or described as limited.
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Abstract
The medical community often assumes that the tests we use to diagnose various diseases are accurate, safe, and effective. However, the study designs traditionally used to determine whether such a diagnostic test is indeed accurate, safe, and effective are often at a higher risk of bias and are of lower methodological quality than those evaluating efficacy of therapeutic interventions. Several designs can be used to study diagnostic tests such as diagnostic accuracy cross-sectional studies, diagnostic accuracy case-control studies, and diagnostic accuracy comparative studies. Clinicians, researchers, and policy-makers may wish to consider moving toward higher quality study designs when studying new diagnostic modalities prior to their implementation in routine practice and diagnostic randomized trials are one such alternative.
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Affiliation(s)
- Michaël Chassé
- Department of Medicine (Critical Care), University of Montreal Hospital, Montreal, Canada; University of Montreal Hospital Research Center (CRCHUM), Montreal, Canada.
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
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Kempny A, McCabe C, Dimopoulos K, Price LC, Wilde M, Limbrey R, Gatzoulis MA, Wort SJ. Incidence, mortality and bleeding rates associated with pulmonary embolism in England between 1997 and 2015. Int J Cardiol 2018; 277:229-234. [PMID: 30448018 DOI: 10.1016/j.ijcard.2018.10.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 08/28/2018] [Accepted: 10/01/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND Improvements in availability and accuracy of diagnostic testing in pulmonary embolism (PE) in the last 20 years have more recently been paralleled by the introduction of additional anticoagulation agents and treatment strategies. These developments are likely to shape potentially important changes in PE incidence, associated mortality and treatment complications. METHODS We investigated trends in PE incidence, PE-related mortality and bleeding risk by analysing Hospital Episodes Statistics for England. RESULTS Between 1997 and 2015, 464,046 patients (53.9% female) were hospitalized with PE in England. The annual number of hospitalizations with an associated diagnosis of PE more than doubled over this period (24,366 in 1998 vs. 53,108 in 2014), with a corresponding increase in PE hospitalization rate (50.2 to 97.8 per 100,000 population/year), evident in all age categories. Mortality at 1 and 3 months decreased over the study period and was significantly associated with age, treatment era and comorbidities. The risk of bleeding resulting in hospitalization or death within 3 and 12 months after the index PE admission increased over the study period (4.3%/5.1% for 1998-2004 versus 6.1%/7.2% for 2010-2014, p < 0.001 for both comparisons). CONCLUSIONS The incidence of PE doubled in England between 1997 and 2015, likely attributable to raised awareness and ability to diagnose less severe cases. While PE-associated mortality decreased, there was an increase in bleeding risk. Renewed efforts directed at reducing the incidence of bleeding, including consideration of anticoagulation regimens and investigation of anticoagulation requirement in patients with low-risk features, are needed.
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Affiliation(s)
- Aleksander Kempny
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, Imperial College, London, UK.
| | - Colm McCabe
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, Imperial College, London, UK
| | - Konstantinos Dimopoulos
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, Imperial College, London, UK
| | - Laura C Price
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, Imperial College, London, UK
| | - Michael Wilde
- Respiratory and Pulmonary Hypertension Service, Surrey and Sussex Healthcare NHS Trust, Redhill, UK
| | - Rachel Limbrey
- Respiratory Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Michael A Gatzoulis
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, Imperial College, London, UK
| | - Stephen J Wort
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, Imperial College, London, UK
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22
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van der Pol LM, Bistervels IM, van Mens TE, van der Hulle T, Beenen LFM, den Exter PL, Kroft LJM, Mairuhu ATA, Middeldorp S, van Werkhoven JM, Ten Wolde M, Huisman MV, Klok FA. Lower prevalence of subsegmental pulmonary embolism after application of the YEARS diagnostic algorithm. Br J Haematol 2018; 183:629-635. [PMID: 30198551 PMCID: PMC6282699 DOI: 10.1111/bjh.15556] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 05/29/2018] [Indexed: 12/11/2022]
Abstract
The rate of identified isolated subsegmental pulmonary embolism (ssPE) has doubled with advances in computed tomography pulmonary angiography (CTPA) technology, but its clinical relevance is debated. The YEARS diagnostic algorithm was shown to safely reduce the number of required CTPAs in the diagnostic management of PE. We hypothesized that the higher threshold for performing CTPA in YEARS was associated with a lower prevalence of ssPE compared to the conventional diagnostic algorithm. We compared 2291 consecutive patients with suspected PE managed according to YEARS to 3306 consecutive control patients managed according to the Wells score for the prevalence of isolated ssPE. In the YEARS cohort, 52% were managed without CTPA, 12% had pulmonary embolism (PE) of which 10% were isolated ssPE, and the 3‐month diagnostic failure rate was 0·35%. In the control cohort, 32% were managed without CTPA, 20% had PE of which 16% were isolated ssPE, and the 3‐month failure rate was 0·73%. The isolated ssPE prevalence was significantly lower in YEARS (absolute difference 6·2% (95% confidence interval [CI] 1·4–10), Odds Ratio 0·58 (95% CI 0·37–0·90). In conclusion, YEARS is associated with a lower prevalence of isolated ssPE, due to reduction in CTPAs by the higher D‐dimer threshold. This was however not associated with a higher risk of recurrent VTE during follow‐up.
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Affiliation(s)
- Liselotte M van der Pol
- Department of Thrombosis and Haemostasis, Leiden University Medical Centre, Leiden, The Netherlands.,Department of Internal Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | - Ingrid M Bistervels
- Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands.,Department of Internal Medicine, Flevo Hospital, Almere, The Netherlands
| | - Thijs E van Mens
- Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Tom van der Hulle
- Department of Thrombosis and Haemostasis, Leiden University Medical Centre, Leiden, The Netherlands
| | - Ludo F M Beenen
- Department of Radiology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Paul L den Exter
- Department of Thrombosis and Haemostasis, Leiden University Medical Centre, Leiden, The Netherlands
| | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Albert T A Mairuhu
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | - Saskia Middeldorp
- Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | | | - Marije Ten Wolde
- Department of Internal Medicine, Flevo Hospital, Almere, The Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Haemostasis, Leiden University Medical Centre, Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Haemostasis, Leiden University Medical Centre, Leiden, The Netherlands
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Bariteau A, Stewart LK, Emmett TW, Kline JA. Systematic Review and Meta-analysis of Outcomes of Patients With Subsegmental Pulmonary Embolism With and Without Anticoagulation Treatment. Acad Emerg Med 2018; 25:828-835. [PMID: 29498138 DOI: 10.1111/acem.13399] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 02/07/2018] [Accepted: 02/25/2018] [Indexed: 01/02/2023]
Abstract
BACKGROUND This systematic review addresses the controversy over the decision to anticoagulate patients with subsegmental pulmonary embolism (SSPE). METHODS We searched Ovid MEDLINE, PubMed, Embase, the Cochrane Library, Scopus, Web of Science, ClinicalTrials.gov, Google Scholar, and bibliographies in March 2017. Two authors reviewed and retained papers with symptomatic patients who underwent computerized tomographic pulmonary angiography and had sufficient information to determine SSPE; decision to treat (or not) with systemic anticoagulation; and outcomes of bleeding, venous thromboembolism (VTE) recurrence, and death. Papers were assessed for selection and publication bias and heterogeneity, with Eggers and the inconsistency indexes (I2 ). RESULTS From 1,512 papers screened, we included 14 studies comprising 15,563 patients for full-length review and analysis. Pooled data demonstrated I2 = 99% with an Eggers p < 0.001, suggesting significant publication bias. The pooled prevalence of SSPE was 4.6% (95% confidence interval [CI] = 1.8%-8.5%). The frequency of bleeding in SSPE patients treated with anticoagulation (n = 589) was 8.1% (95% CI = 2.8%-15.8%), with no available bleeding data in untreated patients (n = 126). The frequency of VTE recurrence within 90 days was 5.3% (95% CI = 1.6%-10.9%) for treated versus 3.9% (95% CI = 4.8%-13.4%) for untreated, while the frequency of death was 2.1% (95% CI = 3.4%-5.2%) for treated versus 3.0% (95% CI = 2.8%-8.6%) for untreated. CONCLUSION This systematic review highlights the lack of any clinical trial to make a clear inference about harm or benefit of anticoagulation for SSPE. Comparison of pooled data from uncontrolled outcome studies shows no increase in VTE recurrence or death rates for patients who were not anticoagulated. These data suggest clinical equipoise for decision to anticoagulate or not anticoagulate patients with SSPE. However, this inference is limited by small numbers, imprecision, and the lack of a controlled clinical trial.
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Affiliation(s)
- Adam Bariteau
- Department of Emergency Medicine Indiana University School of Medicine Indianapolis IN
| | - Lauren K. Stewart
- Department of Emergency Medicine Indiana University School of Medicine Indianapolis IN
| | - Thomas W. Emmett
- Ruth Lilly Medical Library Indiana University School of Medicine Indianapolis IN
| | - Jeffrey A. Kline
- Department of Emergency Medicine Indiana University School of Medicine Indianapolis IN
- Department of Cellular and Integrative Physiology Indiana University School of Medicine Indianapolis IN
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Tsuchiya N, Beek EJRV, Ohno Y, Hatabu H, Kauczor HU, Swift A, Vogel-Claussen J, Biederer J, Wild J, Wielpütz MO, Schiebler ML. Magnetic resonance angiography for the primary diagnosis of pulmonary embolism: A review from the international workshop for pulmonary functional imaging. World J Radiol 2018; 10:52-64. [PMID: 29988845 PMCID: PMC6033703 DOI: 10.4329/wjr.v10.i6.52] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Revised: 04/25/2018] [Accepted: 05/30/2018] [Indexed: 02/06/2023] Open
Abstract
Pulmonary contrast enhanced magnetic resonance angiography (CE-MRA) is useful for the primary diagnosis of pulmonary embolism (PE). Many sites have chosen not to use CE-MRA as a first line of diagnostic tool for PE because of the speed and higher efficacy of computerized tomographic angiography (CTA). In this review, we discuss the strengths and weaknesses of CE-MRA and the appropriate imaging scenarios for the primary diagnosis of PE derived from our unique multi-institutional experience in this area. The optimal patient for this test has a low to intermediate suspicion for PE based on clinical decision rules. Patients in extremis are not candidates for this test. Younger women (< 35 years of age) and patients with iodinated contrast allergies are best served by using this modality We discuss the history of the use of this test, recent technical innovations, artifacts, direct and indirect findings for PE, ancillary findings, and the effectiveness (patient outcomes) of CE-MRA for the exclusion of PE. Current outcomes data shows that CE-MRA and NM V/Q scans are effective alternative tests to CTA for the primary diagnosis of PE.
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Affiliation(s)
- Nanae Tsuchiya
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, Okinawa 903-0215, Japan
- Department of Radiology, University of Wisconsin-Madison, Madison, WI 53792, United States
| | - Edwin JR van Beek
- Edinburgh Imaging, Queen’s Medical Research Institute, University of Edinburgh, Edinburgh EH16 4TJ, United Kingdom
| | - Yoshiharu Ohno
- Division of Functional and Diagnostic Imaging Research, Department of Radiology, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan
| | - Hiroto Hatabu
- Department of Radiology, Brigham and Women’s Hospital, Boston, MA 02115, United States
| | - Hans-Ulrich Kauczor
- Department of Diagnostic and Interventional Radiology, University Hospital of Heidelberg, Heidelberg 69120, Germany
| | - Andrew Swift
- Department of Radiology, Royal Hallamshire Hospital, University of Sheffield, Sheffield S10 2JF, United Kingdom
| | - Jens Vogel-Claussen
- Department of Radiology, Carl-Neuberg Strasse 1, Hannover-Gr-Buchholz 30625, Germany
| | - Jürgen Biederer
- Radiology Darmstadt, Gross-Gerau County Hospital, Gross-Gerau 64521, Germany
| | - James Wild
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield S10 2JF, United Kingdom
| | - Mark O Wielpütz
- Department of Diagnostic and Interventional Radiology, University Hospital of Heidelberg, Heidelberg 69120, Germany
| | - Mark L Schiebler
- Department of Radiology, University of Wisconsin-Madison, Madison, WI 53792, United States
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Russell LA, Sigmund AE, Szymonifka J, Jawetz ST, Grond SE, Dey SA, Bass AR. Does my patient have a pulmonary embolism? The Wells vs. PISA 2 rule in orthopedic patients. J Thromb Thrombolysis 2018; 45:417-422. [PMID: 29372399 DOI: 10.1007/s11239-018-1618-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
The diagnosis of venous thromboembolism is difficult in the postoperative setting because signs such as hypoxemia, leg pain, and swelling are so common. CTPA can also detect subsegmental PE (SSPE), of which the clinical significance has been widely debated. Clinical decision rules (CDR), such as the Wells and PISA 2, have been developed to identify symptomatic patients at low risk for PE who could forgo imaging. We performed this study in order to (1) compare the performance of the Wells and PISA 2 CDR in orthopedic patients; (2) compare CDR scores in patients with subsegmental PE (SSPE) versus larger clots; and (3) identify variables that improve performance of the Wells in orthopedic patients. This retrospective cohort study included all orthopedic surgery patients that underwent computerized tomographic pulmonary angiography at a single institution from 1/1/13 to 12/31/14 and had data to calculate both Wells and PISA 2 scores. CDR sensitivity, specificity and c-statistics were calculated. Multivariable logistic regression was used to identify variables that improved CDR performance. 402 patients were included in the study. The Wells rule (cutoff > 4) had sensitivity 74% and specificity 45%. PISA 2 (cutoff 0.6) had sensitivity 90% and specificity 11%. The Wells performed better than PISA 2: c-statistic 0.60 vs. 0.50; p = 0.007. The mean Wells score was 5.20 ± 1.68 for patients with SSPE and 5.41 ± 1.86 for patients with larger clots. Adding the variables prior smoking and varicose veins improved the performance of the Wells rule (c-statistic 0.66 vs. 0.60, p = 0.008). The Wells rule (cutoff > 4) performs better than PISA 2 in orthopedic patients. Neither can distinguish patients with SSPE from those with larger clots. Although adding past smoking and varicose veins to the Wells improves its performance, this requires validation in other populations.
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Affiliation(s)
- Linda A Russell
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA.
| | - Alana E Sigmund
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Jackie Szymonifka
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Shari T Jawetz
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Sarah E Grond
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Shirin A Dey
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Anne R Bass
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
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Abstract
Advances in the management of patients with suspected pulmonary embolism (PE) have improved diagnostic accuracy and made management algorithms safer, easier to use, and well standardized. These diagnostic algorithms are mainly based on the assessment of clinical pretest probability, D-dimer measurement, and imaging tests-predominantly computed tomography pulmonary angiography. These diagnostic algorithms allow safe and cost-effective diagnosis for most patients with suspected PE. In this review, we summarize signs and symptoms of PE, current existing evidence for PE diagnosis, and focus on the challenge of diagnosing PE in special patient populations, such as pregnant women, or patients with a prior VTE. We also discuss novel imaging tests for PE diagnosis and highlight some of the additional challenges that might require adjustments to current diagnostic strategies, such as the reduced clinical suspicion threshold, resulting in a lower proportion of PE among suspected patients as well as the overdiagnosis of subsegmental PE.
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Affiliation(s)
- M Righini
- Division of Angiology and Hemostasis, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland
| | - H Robert-Ebadi
- Division of Angiology and Hemostasis, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland
| | - G Le Gal
- Ottawa Hospital Research Institute, Ottawa, Canada
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Carrillo Alcaraz A, Martínez AL, Solano FS. Diagnóstico de la embolia pulmonar. El punto de vista del médico clínico. RADIOLOGIA 2017; 59:166-176. [DOI: 10.1016/j.rx.2016.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 10/02/2016] [Accepted: 10/14/2016] [Indexed: 12/27/2022]
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Best Clinical Practice: Current Controversies in Pulmonary Embolism Imaging and Treatment of Subsegmental Thromboembolic Disease. J Emerg Med 2017; 52:184-193. [DOI: 10.1016/j.jemermed.2016.08.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Revised: 08/05/2016] [Accepted: 08/22/2016] [Indexed: 12/14/2022]
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Ghazvinian R, Gottsäter A, Elf J. Is it safe to withhold long-term anticoagulation therapy in patients with small pulmonary emboli diagnosed by SPECT scintigraphy? Thromb J 2016; 14:12. [PMID: 27247527 PMCID: PMC4886445 DOI: 10.1186/s12959-016-0086-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 05/25/2016] [Indexed: 01/01/2023] Open
Abstract
Background The need for anticoagulation therapy (AC) in patients with subsegmental pulmonary embolism (SSPE) diagnosed by computed tomography of the pulmonary arteries (CTPA) has been questioned, as these patients run low risk for recurrent venous thromboembolism (VTE) during 3 months of follow-up. Whether this applies also to patients with small PE diagnosed with pulmonary scintigraphy has not yet been evaluated, however. Methods We therefore retrospectively evaluated 54 patients (mean age 62 ± 19 years, 36 [67 %] women) with small PE diagnosed by ventilation/perfusion singe photon emission computed tomography (V/P SPECT) who did not receive conventional long-term AC. Results More than half of our patients (36[67 %]) received less than 48 h of AC, 11 (20 %) patients were treated for 2–14 days, and 7 (13 %) for 15–30 days. The majority (28 [52 %]) of our patients had a non-low simplified pulmonary emboli severity index (S-PESI), and 7 (13 %) had malignancy. D-dimer was negative in 18 (33 %), positive in 10 (19 %), and not analyzed in 28 (52 %) patients. Phlebography of the lower extremities had been performed with negative result in one patient. During 90 days of follow up no deaths or PE occurred. Seven patients were readmitted to hospital, whereof two (2/54 [4 %]) were diagnosed with deep venous thrombosis (DVT) necessitating AC therapy. Conclusion In conclusion, withholding longterm AC therapy in patients with SSPE diagnosed by V/P SPECT resulted in 4 % risk for recurrence of VTE during 90 days of follow up, and can therefore currently not be recommended.
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Affiliation(s)
- R Ghazvinian
- Lund University, Division of Vascular Medicine, Skåne University Hospital, Ruth Lundskogs Gata 10, S-205 02 Malmö, Sweden
| | - A Gottsäter
- Lund University, Division of Vascular Medicine, Skåne University Hospital, Ruth Lundskogs Gata 10, S-205 02 Malmö, Sweden
| | - J Elf
- Lund University, Division of Vascular Medicine, Skåne University Hospital, Ruth Lundskogs Gata 10, S-205 02 Malmö, Sweden
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Yazdani M, Lau CT, Lempel JK, Yadav R, El-Sherief AH, Azok JT, Renapurkar RD. Historical Evolution of Imaging Techniques for the Evaluation of Pulmonary Embolism. Radiographics 2016; 35:1245-62. [PMID: 26172362 DOI: 10.1148/rg.2015140280] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
As we celebrate the 100th anniversary of the founding of the Radiological Society of North America (RSNA), it seems fitting to look back at the major accomplishments of the radiology community in the diagnosis of pulmonary embolism. Few diseases have so consistently captured the attention of the medical community. Since the first description of pulmonary embolism by Virchow in the 1850s, clinicians have struggled to reach a timely diagnosis of this common condition because of its nonspecific and often confusing clinical picture. As imaging tests started to gain importance in the 1900s, the approach to diagnosing pulmonary embolism also began to change. Rapid improvements in angiography, ventilation-perfusion imaging, and cross-sectional imaging modalities such as computed tomography (CT) and magnetic resonance imaging have constantly forced health care professionals to rethink how they diagnose pulmonary embolism. Needless to say, the way pulmonary embolism is diagnosed today is distinctly different from how it was diagnosed in Virchow's era; and imaging, particularly CT, now forms the cornerstone of diagnostic evaluation. Currently, radiology offers a variety of tests that are fast and accurate and can provide anatomic and functional information, thus allowing early diagnosis and triage of cases. This review provides a historical journey into the evolution of these imaging tests and highlights some of the major breakthroughs achieved by the radiology community and RSNA in this process. Also highlighted are areas of ongoing research and development in this field of imaging as radiologists seek to combat some of the newer challenges faced by modern medicine, such as rising health care costs and radiation dose hazards.
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Affiliation(s)
- Milad Yazdani
- From the Sections of Thoracic Imaging (M.Y., C.T.L., J.K.L., R.Y., A.H.E., J.T.Z., R.D.R.) and Nuclear Medicine (R.Y., R.D.R.), Imaging Institute, Thoracic Imaging L10, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195
| | - Charles T Lau
- From the Sections of Thoracic Imaging (M.Y., C.T.L., J.K.L., R.Y., A.H.E., J.T.Z., R.D.R.) and Nuclear Medicine (R.Y., R.D.R.), Imaging Institute, Thoracic Imaging L10, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195
| | - Jason K Lempel
- From the Sections of Thoracic Imaging (M.Y., C.T.L., J.K.L., R.Y., A.H.E., J.T.Z., R.D.R.) and Nuclear Medicine (R.Y., R.D.R.), Imaging Institute, Thoracic Imaging L10, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195
| | - Ruchi Yadav
- From the Sections of Thoracic Imaging (M.Y., C.T.L., J.K.L., R.Y., A.H.E., J.T.Z., R.D.R.) and Nuclear Medicine (R.Y., R.D.R.), Imaging Institute, Thoracic Imaging L10, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195
| | - Ahmed H El-Sherief
- From the Sections of Thoracic Imaging (M.Y., C.T.L., J.K.L., R.Y., A.H.E., J.T.Z., R.D.R.) and Nuclear Medicine (R.Y., R.D.R.), Imaging Institute, Thoracic Imaging L10, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195
| | - Joseph T Azok
- From the Sections of Thoracic Imaging (M.Y., C.T.L., J.K.L., R.Y., A.H.E., J.T.Z., R.D.R.) and Nuclear Medicine (R.Y., R.D.R.), Imaging Institute, Thoracic Imaging L10, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195
| | - Rahul D Renapurkar
- From the Sections of Thoracic Imaging (M.Y., C.T.L., J.K.L., R.Y., A.H.E., J.T.Z., R.D.R.) and Nuclear Medicine (R.Y., R.D.R.), Imaging Institute, Thoracic Imaging L10, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195
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Mao X, Wang S, Jiang X, Zhang L, Xu W. Diagnostic Value of Dual-Source Computerized Tomography Combined with Perfusion Imaging for Peripheral Pulmonary Embolism. IRANIAN JOURNAL OF RADIOLOGY : A QUARTERLY JOURNAL PUBLISHED BY THE IRANIAN RADIOLOGICAL SOCIETY 2016; 13:e29402. [PMID: 27703656 PMCID: PMC5039736 DOI: 10.5812/iranjradiol.29402] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 02/06/2016] [Accepted: 02/14/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pulmonary embolism has become the third most common cardiovascular disease, which can seriously harm human health. OBJECTIVES To investigate the diagnostic value of dual-source computerized tomography (CT) and perfusion imaging for peripheral pulmonary embolism. PATIENTS AND METHODS Thirty-two patients with suspected pulmonary embolism underwent dual-source CT exams. To compare the ability of pulmonary embolism detection software (PED) with CT pulmonary angiography (CTPA) in determining the presence, numbers, and locations of pulmonary emboli, the subsequent images were reviewed by two radiologists using both imaging modalities. Also, the diagnostic consistency between PED and CTPA images and dual-energy pulmonary perfusion imaging (DEPI) for segmental pulmonary embolism was compared. RESULTS CTPA images revealed 50 (7.81%) segmental and 56 (4.38%) sub-segmental pulmonary embolisms, while the PED images showed 68 (10.63%) segmental and 94 (7.34%) sub-segmental pulmonary embolisms. Thus, the detection rate on PED images for peripheral pulmonary embolism was significantly higher than that of the CTPA images (P < 0.05). There was good consistency for diagnosing segmental pulmonary embolism between PED and CTPA and DEPI (kappa = 0.85). The sensitivity and specificity of DEPI images for the diagnosis of pulmonary embolism were 91.7% and 97.5%, respectively. CONCLUSION PED software of dual-source CT combined with perfusion imaging can significantly improve the detection rate of peripheral pulmonary embolism.
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Affiliation(s)
- Xijin Mao
- Department of Radiology, Affiliated Hospital of Qingdao University, Qingdao, China
- Department of Radiology, Affiliated Hospital of Binzhou Medical College, Binzhou, China
| | - Shanshan Wang
- Department of Radiology, Affiliated Hospital of Binzhou Medical College, Binzhou, China
| | - Xingyue Jiang
- Department of Radiology, Affiliated Hospital of Binzhou Medical College, Binzhou, China
| | - Lin Zhang
- Department of Radiology, Affiliated Hospital of Binzhou Medical College, Binzhou, China
| | - Wenjian Xu
- Department of Radiology, Affiliated Hospital of Qingdao University, Qingdao, China
- Corresponding author: Wenjian Xu, Department of Radiology, Affiliated Hospital of Qingdao University, Qingdao, China. Tel: +86-13963952822, Fax: +86-53282824980, E-mail:
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Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest 2016; 149:315-352. [PMID: 26867832 DOI: 10.1016/j.chest.2015.11.026] [Citation(s) in RCA: 3232] [Impact Index Per Article: 404.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 11/24/2015] [Accepted: 11/25/2015] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND We update recommendations on 12 topics that were in the 9th edition of these guidelines, and address 3 new topics. METHODS We generate strong (Grade 1) and weak (Grade 2) recommendations based on high- (Grade A), moderate- (Grade B), and low- (Grade C) quality evidence. RESULTS For VTE and no cancer, as long-term anticoagulant therapy, we suggest dabigatran (Grade 2B), rivaroxaban (Grade 2B), apixaban (Grade 2B), or edoxaban (Grade 2B) over vitamin K antagonist (VKA) therapy, and suggest VKA therapy over low-molecular-weight heparin (LMWH; Grade 2C). For VTE and cancer, we suggest LMWH over VKA (Grade 2B), dabigatran (Grade 2C), rivaroxaban (Grade 2C), apixaban (Grade 2C), or edoxaban (Grade 2C). We have not changed recommendations for who should stop anticoagulation at 3 months or receive extended therapy. For VTE treated with anticoagulants, we recommend against an inferior vena cava filter (Grade 1B). For DVT, we suggest not using compression stockings routinely to prevent PTS (Grade 2B). For subsegmental pulmonary embolism and no proximal DVT, we suggest clinical surveillance over anticoagulation with a low risk of recurrent VTE (Grade 2C), and anticoagulation over clinical surveillance with a high risk (Grade 2C). We suggest thrombolytic therapy for pulmonary embolism with hypotension (Grade 2B), and systemic therapy over catheter-directed thrombolysis (Grade 2C). For recurrent VTE on a non-LMWH anticoagulant, we suggest LMWH (Grade 2C); for recurrent VTE on LMWH, we suggest increasing the LMWH dose (Grade 2C). CONCLUSIONS Of 54 recommendations included in the 30 statements, 20 were strong and none was based on high-quality evidence, highlighting the need for further research.
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Peiman S, Abbasi M, Allameh SF, Asadi Gharabaghi M, Abtahi H, Safavi E. Subsegmental pulmonary embolism: A narrative review. Thromb Res 2015; 138:55-60. [PMID: 26702485 DOI: 10.1016/j.thromres.2015.12.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Revised: 11/27/2015] [Accepted: 12/08/2015] [Indexed: 12/12/2022]
Abstract
Through the introduction of computed tomography pulmonary angiography (CTPA) for diagnosis of the pulmonary embolism (PE), the high sensitivity of this diagnostic tool led to detecting peripheral filling defects as small as 2-3mm, termed as subsegmental pulmonary embolism (SSPE). However, despite these substantial increases in diagnosis of small pulmonary embolism, there are minimal changes in mortality. Moreover, SSPE patients generally are hemodynamically stable with mild clinical presentation, lower serum level of biomarkers, lower incidence of associated proximal DVTs and less frequent echocardiographic changes compared to the patients with emboli located in more central pulmonary arteries. However, the pros and cons of anticoagulant therapy versus non-treating, monitoring protocol and exact long term outcome of these patients are still unclear. In this article we review existing evidence and provide an overview of what is known about the diagnosis and management of subsegmental pulmonary embolism.
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Affiliation(s)
- Soheil Peiman
- Advanced Thoracic Research Center, Tehran University of Medical Sciences, Tehran, Iran; Department of Internal Medicine, Tehran University of Medical Sciences, Tehran, Iran.
| | - Mehrshad Abbasi
- Department of Nuclear Medicine, Vali-asr Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Farshad Allameh
- Department of Internal Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Hamidreza Abtahi
- Advanced Thoracic Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Enayat Safavi
- Advanced Thoracic Research Center, Tehran University of Medical Sciences, Tehran, Iran
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Abstract
OBJECTIVE The purpose of this study is to evaluate the rate of overdiagnosis of pulmonary embolism (PE) by pulmonary CT angiography (CTA) in a tertiary-care university hospital. MATERIALS AND METHODS This study is a retrospective review of all pulmonary CTA examinations performed in a tertiary-care university hospital over a 12-month period. Studies originally reported as positive for PE were retrospectively reinterpreted by three subspecialty chest radiologists with more than 10 years' experience. A pulmonary CTA was considered negative for PE when all three chest radiologists were in agreement that the pulmonary CTA study was negative for PE. The location and potential causes for PE overdiagnosis were recorded. RESULTS A total of 937 pulmonary CTA studies were performed over the study period. PE was diagnosed in the initial report in 174 of these cases (18.6%). There was discordance between the chest radiologists and the original radiologist in 45 of 174 (25.9%) cases. Discordance occurred more often where the original reported PE was solitary (46.2% of reported solitary PEs were considered negative on retrospective review) and located in a segmental or subsegmental pulmonary artery (26.8% of segmental and 59.4% of subsegmental PE diagnoses were considered negative on retrospective review). The most common cause of diagnostic difficulty was breathing motion artifact, followed by beam-hardening artifact. CONCLUSION In routine clinical practice, PEs diagnosed by pulmonary CTA are frequently overdiagnosed, when compared with the consensus opinion of a panel of expert chest radiologists. Improvements in the quality of pulmonary CTA examination and increased familiarity with potential diagnostic pitfalls in pulmonary CTA are recommended to minimize misdiagnosis of PE.
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Tang CX, Schoepf UJ, Chowdhury SM, Fox MA, Zhang LJ, Lu GM. Multidetector computed tomography pulmonary angiography in childhood acute pulmonary embolism. Pediatr Radiol 2015; 45:1431-9. [PMID: 25846076 PMCID: PMC4553120 DOI: 10.1007/s00247-015-3336-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2014] [Revised: 02/03/2015] [Accepted: 03/02/2015] [Indexed: 12/29/2022]
Abstract
Pulmonary embolism is a life-threatening condition affecting people of all ages. Multidetector row CT pulmonary angiography has improved the imaging of pulmonary embolism in both adults and children and is now regarded as the routine modality for detection of pulmonary embolism. Advanced CT pulmonary angiography techniques developed in recent years, such as dual-energy CT, have been applied as a one-stop modality for pulmonary embolism diagnosis in children, as they can simultaneously provide anatomical and functional information. We discuss CT pulmonary angiography techniques, common and uncommon findings of pulmonary embolism in both conventional and dual-energy CT pulmonary angiography, and radiation dose considerations.
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Affiliation(s)
- Chun Xiang Tang
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, China
| | - U. Joseph Schoepf
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, China. Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA. Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | | | - Mary A. Fox
- Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA
| | - Long Jiang Zhang
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, China
| | - Guang Ming Lu
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, China
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Morgan C, Choi H. BET 1: Do patients with a clinically suspected subsegmental pulmonary embolism need anticoagulation therapy?: Table 1. Emerg Med J 2015; 32:744-7. [DOI: 10.1136/emermed-2015-205210.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Mehta D, Barnett M, Zhou L, Woulfe T, Rolfe-Vyson V, Rowland V, Simpson D, Merriman E. Management and outcomes of single subsegmental pulmonary embolus: a retrospective audit at North Shore Hospital, New Zealand. Intern Med J 2015; 44:872-6. [PMID: 24942202 DOI: 10.1111/imj.12507] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2014] [Accepted: 06/13/2014] [Indexed: 12/18/2022]
Abstract
BACKGROUND It is unknown whether filling defects in subsegmental arteries on multidetector computed tomography pulmonary angiography correlate with clinically relevant subsegmental pulmonary embolism (PE) on pulmonary angiography. Current guidelines do not differentiate between PE in segmental and subsegmental vessels, and many patients receive at least 3 months anticoagulation. The strategy employed at North Shore Hospital in haemodynamically stable patients with single subsegmental PE is to perform bilateral lower leg compression ultrasound (CUS). Anticoagulation is withheld if CUS is negative; a bilateral CUS is repeated in 7-10 days. AIM The aim of this retrospective audit was to ensure our current management strategy is safe. METHODS All diagnoses of single subsegmental PE between June 2005 and June 2013 were included. The primary outcome was the rate of venous thromboembolism (VTE) recurrence within 3 months of single subsegmental PE diagnosis. Secondary outcomes were rates of major/minor bleeding and all-cause mortality. RESULTS Thirty-two patients were included - 20 were treated with anticoagulation; 12 were managed with observation/serial bilateral lower limb CUS. None of the patients in either group had VTE recurrence by 3 months. No bleeding episodes were observed in the observation group; there was a 10% major bleeding rate (n = 2) in the treatment group. One death occurred in each group, neither of which was attributed to VTE. CONCLUSION Withholding anticoagulation in patients with single subsegmental PE and negative serial bilateral CUS appears to be a safe and effective management strategy, with a low risk of VTE recurrence.
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Affiliation(s)
- D Mehta
- Department of Radiology, North Shore Hospital, Auckland, New Zealand
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Kline JA, Russell FM, Lahm T, Mastouri RA. Derivation of a screening tool to identify patients with right ventricular dysfunction or tricuspid regurgitation after negative computerized tomographic pulmonary angiography of the chest. Pulm Circ 2015; 5:171-83. [PMID: 25992280 DOI: 10.1086/679723] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 09/12/2014] [Indexed: 02/02/2023] Open
Abstract
Many dyspneic patients who undergo computerized tomographic pulmonary angiography (CTPA) for presumed acute pulmonary embolism (PE) have no identified cause for their dyspnea yet have persistent symptoms, leading to more CTPA scanning. Right ventricular (RV) dysfunction or overload can signal treatable causes of dyspnea. We report the rate of isolated RV dysfunction or overload after negative CTPA and derive a clinical decision rule (CDR). We performed secondary analysis of a multicenter study of diagnostic accuracy for PE. Inclusion required persistent dyspnea and no PE. Echocardiography was ordered at clinician discretion. A characterization of isolated RV dysfunction or overload required normal left ventricular function and RV hypokinesis, or estimated RV systolic pressure of at least 40 mmHg. The CDR was derived from bivariate analysis of 97 candidate variables, followed by multivariate logistic regression. Of 647 patients, 431 had no PE and persistent dyspnea, and 184 (43%) of these 431 had echocardiography ordered. Of these, 64 patients (35% [95% confidence interval (CI): 28%-42%]) had isolated RV dysfunction or overload, and these patients were significantly more likely to have a repeat CTPA within 90 days (P = .02, [Formula: see text] test). From univariate analysis, 4 variables predicted isolated RV dysfunction: complete right bundle branch block, normal CTPA scan, active malignancy, and CTPA with infiltrate, the last negatively. Logistic regression found only normal CTPA scanning significant. The final rule (persistent dyspnea + normal CTPA scan) had a positive predictive value of 53% (95% CI: 37%-69%). We conclude that a simple CDR consisting of persistent dyspnea plus a normal CTPA scan predicts a high probability of isolated RV dysfunction or overload on echocardiography.
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Affiliation(s)
- Jeffrey A Kline
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA ; Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Frances M Russell
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Tim Lahm
- Division of Pulmonary, Allergy, Critical Care, Occupational and Sleep Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA; and Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana, USA
| | - Ronald A Mastouri
- Division of Cardiology, Indiana University School of Medicine, Indianapolis, Indiana, USA; and Eskenazi Health Center, Indianapolis, Indiana, USA
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Okada M, Kunihiro Y, Nakashima Y, Nomura T, Kudomi S, Yonezawa T, Suga K, Matsunaga N. Added value of lung perfused blood volume images using dual-energy CT for assessment of acute pulmonary embolism. Eur J Radiol 2015; 84:172-177. [DOI: 10.1016/j.ejrad.2014.09.009] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Revised: 08/29/2014] [Accepted: 09/11/2014] [Indexed: 12/01/2022]
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Angriman F, Ferreyro BL, Posadas-Martinez ML, Giunta D, Vazquez FJ, Vollmer WM. Wells Score and Poor Outcomes Among Adult Patients With Subsegmental Pulmonary Embolism. Clin Appl Thromb Hemost 2014; 21:539-45. [DOI: 10.1177/1076029614559772] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction: Since the introduction of computed tomography pulmonary angiography, isolated subsegmental pulmonary embolism has become a commonly recognized clinical problem, but its clinical relevance remains unclear. The objective of the present study was to evaluate the extent to which the simplified Wells score discriminates between patients with varying levels of risk of complications after presenting with subsegmental pulmonary embolism. Materials and Methods: Retrospective cohort study. Patients included had subsegmental pulmonary embolism (1 or multiple emboli limited to subsegmental arteries). Primary explanatory variable was the simplified Wells score, categorized as high (>4) or low (≤4). The primary outcome was time to death or new venous thromboembolism. Kaplan-Meier techniques and Cox regression analysis were used to compare the survival experience of patients with high versus low Wells score with and without adjustment for active malignancy, age, Charlson score, previous venous thromboembolism, and previous major surgery in the last 30 days. Main Results: Seventy-nine patients with subsegmental pulmonary embolism were included. Patients with a high Wells score had a 4-fold increased risk of the composite outcome (hazard ratio = 4.2, 95% confidence interval [CI] = 2.0-8.9, P < .001). Other covariates significantly associated with increased risk in univariate analyses included active malignancy, a low serum albumin, and an increased Charlson score. In multivariate Cox regression analyses adjusting for these other factors, a high Wells score remained significant (hazard ratio 5.5, 95% CI 2.4-12.6, P < .001). Conclusion: High Wells score is associated with death or new venous thromboembolism during follow-up among patients with subsegmental pulmonary embolism. Clinical trial registration: ClinicalTrials.gov number, NCT01372514.
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Affiliation(s)
- Federico Angriman
- Internal Medicine Department, Hospital Italiano de Buenos Aires, Buenos Aires University, Buenos Aires, Argentina
| | - Bruno L. Ferreyro
- Internal Medicine Department, Hospital Italiano de Buenos Aires, Buenos Aires University, Buenos Aires, Argentina
| | | | - Diego Giunta
- Internal Medicine Research Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Fernando J. Vazquez
- Internal Medicine Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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Abstract
BACKGROUND Pulmonary embolism (PE) can be a life-threatening emergency. Accurate diagnostic techniques and patient-specific management strategies are necessary to ensure favorable clinical outcomes. METHODS Relevant guidelines, articles, reviews, and abstracts were identified using a narrative approach in PubMed/MEDLINE, Google Scholar, clinicaltrials.gov and nice.org.uk. English-language articles published in 2000-2014 were initially identified using the search terms: novel OAC, pulmonary embolism, venous thromboembolism, diagnosis, treatment, rivaroxaban, apixaban, dabigatran, and edoxaban. The initial literature search was supported by a 'snowballing' style literature search, and relevant articles were included based on a professional judgment of relevance. SCOPE We discuss the diagnosis of PE and the categorization of risk for subgroups, which may assist with making treatment decisions. We review current guidance on acute and long-term treatment, possible limitations of traditional anticoagulant therapy, and the development of direct oral anticoagulants, which may significantly alter the management of patients with PE. Finally, we discuss special considerations in high-risk and hard-to-treat subpopulations that may benefit from the improved benefit-risk profile offered by these newer agents. CONCLUSIONS The direct oral anticoagulants may overcome several of the limitations associated with traditional anticoagulant therapy, potentially improving the standard of care for PE patients, including high-risk and hard-to-manage subgroups.
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Affiliation(s)
- Robert J Walter
- Walter Reed National Military Medical Center , Bethesda, MD , USA
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Yu S, Kumamaru KK, George E, Dunne RM, Bedayat A, Neykov M, Hunsaker AR, Dill KE, Cai T, Rybicki FJ. Classification of CT pulmonary angiography reports by presence, chronicity, and location of pulmonary embolism with natural language processing. J Biomed Inform 2014; 52:386-93. [PMID: 25117751 DOI: 10.1016/j.jbi.2014.08.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Revised: 07/01/2014] [Accepted: 08/01/2014] [Indexed: 11/17/2022]
Abstract
In this paper we describe an efficient tool based on natural language processing for classifying the detail state of pulmonary embolism (PE) recorded in CT pulmonary angiography reports. The classification tasks include: PE present vs. absent, acute PE vs. others, central PE vs. others, and subsegmental PE vs. others. Statistical learning algorithms were trained with features extracted using the NLP tool and gold standard labels obtained via chart review from two radiologists. The areas under the receiver operating characteristic curves (AUC) for the four tasks were 0.998, 0.945, 0.987, and 0.986, respectively. We compared our classifiers with bag-of-words Naive Bayes classifiers, a standard text mining technology, which gave AUC 0.942, 0.765, 0.766, and 0.712, respectively.
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Affiliation(s)
- Sheng Yu
- Partners HealthCare Personalized Medicine, Brigham and Women's Hospital & Harvard Medical School, Boston, MA, United States.
| | - Kanako K Kumamaru
- Applied Imaging Science Laboratory, Department of Radiology, Brigham and Women's Hospital & Harvard Medical School, Boston, MA, United States
| | - Elizabeth George
- Applied Imaging Science Laboratory, Department of Radiology, Brigham and Women's Hospital & Harvard Medical School, Boston, MA, United States
| | - Ruth M Dunne
- Thoracic Imaging, Department of Radiology, Brigham and Women's Hospital & Harvard Medical School, Boston, MA, United States
| | - Arash Bedayat
- Applied Imaging Science Laboratory, Department of Radiology, Brigham and Women's Hospital & Harvard Medical School, Boston, MA, United States; Department of Radiology, University of Massachusetts Medical School, Worcester, MA, United States
| | - Matey Neykov
- Department of Biostatistics, Harvard School of Public Health, Boston, MA, United States
| | - Andetta R Hunsaker
- Thoracic Imaging, Department of Radiology, Brigham and Women's Hospital & Harvard Medical School, Boston, MA, United States
| | - Karin E Dill
- Department of Radiology, University of Chicago, Chicago, IL, United States
| | - Tianxi Cai
- Department of Biostatistics, Harvard School of Public Health, Boston, MA, United States
| | - Frank J Rybicki
- Applied Imaging Science Laboratory, Department of Radiology, Brigham and Women's Hospital & Harvard Medical School, Boston, MA, United States
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García-Sanz M, Pena-Álvarez C, López-Landeiro P, Bermo-Domínguez A, Fontúrbel T, González-Barcala F. Symptoms, location and prognosis of pulmonary embolism. REVISTA PORTUGUESA DE PNEUMOLOGIA 2014; 20:194-9. [DOI: 10.1016/j.rppneu.2013.09.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Revised: 09/05/2013] [Accepted: 09/21/2013] [Indexed: 10/25/2022] Open
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Wiener RS, Ouellette DR, Diamond E, Fan VS, Maurer JR, Mularski RA, Peters JI, Halpern SD. An official American Thoracic Society/American College of Chest Physicians policy statement: the Choosing Wisely top five list in adult pulmonary medicine. Chest 2014; 145:1383-1391. [PMID: 24889436 PMCID: PMC4694177 DOI: 10.1378/chest.14-0670] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 03/19/2014] [Indexed: 12/11/2022] Open
Abstract
The American Board of Internal Medicine Foundation's Choosing Wisely campaign aims to curb health-care costs and improve patient care by soliciting lists from medical societies of the top five tests or treatments in their specialty that are used too frequently and inappropriately. The American Thoracic Society (ATS) and American College of Chest Physicians created a joint task force, which produced a top five list for adult pulmonary medicine. Our top five recommendations, which were approved by the executive committees of the ATS and American College of Chest Physicians and published by Choosing Wisely in October 2013, are as follows: (1) Do not perform CT scan surveillance for evaluation of indeterminate pulmonary nodules at more frequent intervals or for a longer period of time than recommended by established guidelines; (2) do not routinely offer pharmacologic treatment with advanced vasoactive agents approved only for the management of pulmonary arterial hypertension to patients with pulmonary hypertension resulting from left heart disease or hypoxemic lung diseases (groups II or III pulmonary hypertension); (3) for patients recently discharged on supplemental home oxygen following hospitalization for an acute illness, do not renew the prescription without assessing the patient for ongoing hypoxemia; (4) do not perform chest CT angiography to evaluate for possible pulmonary embolism in patients with a low clinical probability and negative results of a highly sensitive D-dimer assay; (5) do not perform CT scan screening for lung cancer among patients at low risk for lung cancer. We hope pulmonologists will use these recommendations to stimulate frank discussions with patients about when these tests and treatments are indicated--and when they are not.
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Affiliation(s)
- Renda Soylemez Wiener
- Pulmonary Center, Boston University School of Medicine, Boston, MA; Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA; The Dartmouth Institute for Health Policy & Clinical Practice, Hanover, NH.
| | - Daniel R Ouellette
- Pulmonary and Critical Care Medicine, Henry Ford Health System, Detroit, MI
| | | | - Vincent S Fan
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, WA; Department of Medicine, University of Washington, Seattle, WA
| | - Janet R Maurer
- Department of Medicine, College of Medicine, The University of Arizona, Phoenix, AZ; Quality Improvement and Compliance, National Imaging Associates/Magellan Health Services, Inc, Phoenix, AZ
| | - Richard A Mularski
- The Center for Health Research, Kaiser Permanente Northwest, Portland, OR; Department of Pulmonary/Critical Care Medicine, Northwest Permanente PC, Portland, OR; Department of Medicine, Oregon Health & Science University, Portland, OR
| | - Jay I Peters
- UT Health Science Center, San Antonio, TX; South Texas Veterans Health Care System, San Antonio, TX
| | - Scott D Halpern
- Departments of Medicine, Biostatistics and Epidemiology, and Medical Ethics and Health Policy, and the Leonard Davis Institute Center for Health Incentives and Behavioral Economics, The University of Pennsylvania, Philadelphia, PA
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Abstract
OBJECTIVES The purpose of this study is to characterize the presentation, size, treatment, and complications of pulmonary embolism (PE) in a large series of orthopaedic trauma patients who developed PE after injury. METHODS We reviewed the records of orthopaedic trauma patients who developed a PE within 6 months of injury at 9 trauma centers and 2 tertiary care facilities. RESULTS There were 312 patients, 186 men and 126 women, average age 58 years. Average body mass index was 29.6, and average Injury Severity Score was 18. Seventeen percent received anticoagulation before injury, and 5% had a history of PE. After injury, 87% were placed on prophylactic anticoagulation and 68% with low-molecular weight heparin. Fifty-three percent of patients exhibited shortness of breath or chest pain. Average heart rate and O2 saturation before PE diagnosis were 110 and 94%, respectively. Thirty-nine percent had abnormal arterial blood gas, and 30% had abnormal electrocardiogram findings. Eighty-nine percent had computed tomography pulmonary angiography for diagnosis. Most clots were segmental (63%), followed by subsegmental (21%), lobar (9%), and central (7%). The most common treatment was unfractionated heparin and Coumadin (25%). Complications of anticoagulation were common: 10% had bleeding at the surgical site. Other complications of anticoagulation included gastrointestinal bleed, anemia, wound complications, death, and compartment syndrome. PE recurred in 1% of patients. Four percent died of PE within 6 months. CONCLUSIONS This is the first large data set to evaluate the course of PE in an orthopaedic trauma population. The complications of anticoagulation are significant and were as common in patients with lower risk clots as those with higher risk clots.
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Missed pulmonary emboli on CT angiography: assessment with pulmonary embolism-computer-aided detection. AJR Am J Roentgenol 2014; 202:65-73. [PMID: 24370130 DOI: 10.2214/ajr.13.11049] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The purpose of this study is to assess the use of a pulmonary embolism (PE)- computer-aided detection (CADx) program in the detection of PE missed in clinical practice. MATERIALS AND METHODS Pulmonary CT angiography (CTA) studies (n = 6769) performed between January 2009 and July 2012 were retrospectively assessed by a thoracic radiologist. In studies that were positive for PE, all prior contrast-enhanced pulmonary CTA studies were reviewed. Missed PE was deemed to have occurred if PE was not described in the final interpretation. The presence, proximal extent, and number of PEs were agreed on by three thoracic radiologists. Studies with missed acute PE and available slice thickness of 2 mm or less were assessed with a prototype PE-CADx program. False-positive PE-CADx marks were analyzed. Outcomes of missed acute PEs were assessed in patients with both follow-up imaging and clinical data. RESULTS Fifty-three studies with overlooked acute PE met our inclusion criteria for PE-CADx assessment. The PE-CADx program identified at least one PE in 77.4% of instances (41/53). PE-CADx correctly marked at least one PE in 23 of 23 cases (100%) with multiple PEs and 18 of 30 (60%) cases with a solitary PE (p < 0.001). PE-CADx per-study sensitivity was significantly higher for segmental (65.5%) than for subsegmental (91.7%) PEs (p = 0.002). PE-CADx averaged 3.8 false-positive marks per case (range, 0-23 marks). Fourteen patients with missed PE who were not receiving anticoagulation therapy developed new PEs, including nine with an isolated subsegmental PE on the initial CT scan. CONCLUSION PE-CADx correctly identified 77.4% of cases of acute PE that were previously missed in clinical practice.
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