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Birrenkott DA, Kabrhel C, Dudzinski DM. Intermediate-Risk and High-Risk Pulmonary Embolism: Recognition and Management: Cardiology Clinics: Cardiac Emergencies. Cardiol Clin 2024; 42:215-235. [PMID: 38631791 DOI: 10.1016/j.ccl.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Pulmonary embolism (PE) is the third most common cause of cardiovascular death. Every specialty of medical practitioner will encounter PE in their patients, and should be prepared to employ contemporary strategies for diagnosis and initial risk-stratification. Treatment of PE is based on risk-stratification, with anticoagulation for all patients, and advanced modalities including systemic thrombolysis, catheter-directed therapies, and mechanical circulatory supports utilized in a manner paralleling PE severity and clinical context.
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Affiliation(s)
- Drew A Birrenkott
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Center for Vascular Emergencies, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Christopher Kabrhel
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Center for Vascular Emergencies, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - David M Dudzinski
- Center for Vascular Emergencies, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Cardiac Intensive Care Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
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2
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Goyal SK, Wang JJ, McCandlish JA, Cronin PP, Barish M, Sanelli PC, Cohen SL. Ten-Year Trend in Advanced Imaging Utilization for Suspected Pulmonary Embolism in Pregnancy. J Am Coll Radiol 2024; 21:549-557. [PMID: 37775066 DOI: 10.1016/j.jacr.2023.08.045] [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: 02/17/2023] [Revised: 08/18/2023] [Accepted: 08/25/2023] [Indexed: 10/01/2023]
Abstract
PURPOSE Advanced imaging is essential to diagnose pulmonary embolism (PE) in pregnancy, but there are associated maternal and fetal radiation risks. The purpose of this study was to evaluate the 10-year trend in advanced imaging utilization for the evaluation of suspected PE in pregnancy. METHODS The authors evaluated pregnant women with advanced imaging using CT pulmonary angiography (CTPA) or lung scintigraphy (LS) for evaluation of suspected PE presenting to two tertiary hospitals from 2007 to 2016. The rate of imaging was evaluated relative to positive PE rate and local pregnancy rate. positive PE was defined as a new acute PE finding on any advanced imaging within 3 days of first advanced imaging test. Local pregnancy rates were defined per 1,000 pregnancies in the county serviced by both hospitals. Chi-square testing was used to evaluate statistical significance (P < .05) in the utilization trend of advanced imaging and relative to local pregnancy rates and evaluations positive for PE. RESULTS A total of 707 pregnant patients were identified, of whom 92.5% (n = 654) underwent CTPA and 7.5% (n = 53) underwent LS. Regression analysis showed an average increase of 5.2 advanced imaging studies per year (P < .001), with 61 and 105 studies performed in 2007 and 2016, respectively. Additionally, there was an average increase of 0.08 (P < .001) advanced imaging studies per 1,000 local pregnancies per year, doubling from 0.7 in 2007 to 1.4 in 2016 (P < .001). Finally, there was a decrease of 0.004 (P = .009) in advanced imaging positive for PE, from 3% (2 of 61) in 2007 to 0% (0 of 100) in 2016. CONCLUSIONS Advanced imaging utilization increased by 72% over the 10-year window, driven by higher use of CTPA. Although the detection rate of PE on advanced imaging has decreased, the utilization rate among pregnant patients doubled during this period. These results highlight the need to consider the radiation risks and costs of advanced imaging in specific patient populations.
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Affiliation(s)
- Sameer K Goyal
- Department of Radiology, Northwell Health, Manhasset, New York
| | - Jason J Wang
- The Feinstein Institutes for Medical Research, Manhasset, New York
| | | | - Paul P Cronin
- Department of Radiology and Imaging Science, Emory University Hospital, Atlanta, Georgia
| | - Matthew Barish
- Department of Radiology, Northwell Health, Manhasset, New York
| | - Pina C Sanelli
- Vice Chairman of Research and Executive Director, Imaging Clinical Effectiveness and Outcomes Research, Manhasset, New York
| | - Stuart L Cohen
- Department of Radiology, Imaging Clinical Effectiveness and Outcomes Research, Manhasset, New York.
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3
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Xi L, Kang H, Deng M, Xu W, Xu F, Gao Q, Xie W, Zhang R, Liu M, Zhai Z, Wang C. A machine learning model for diagnosing acute pulmonary embolism and comparison with Wells score, revised Geneva score, and Years algorithm. Chin Med J (Engl) 2024; 137:676-682. [PMID: 37828028 PMCID: PMC10950185 DOI: 10.1097/cm9.0000000000002837] [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: 05/09/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND Acute pulmonary embolism (APE) is a fatal cardiovascular disease, yet missed diagnosis and misdiagnosis often occur due to non-specific symptoms and signs. A simple, objective technique will help clinicians make a quick and precise diagnosis. In population studies, machine learning (ML) plays a critical role in characterizing cardiovascular risks, predicting outcomes, and identifying biomarkers. This work sought to develop an ML model for helping APE diagnosis and compare it against current clinical probability assessment models. METHODS This is a single-center retrospective study. Patients with suspected APE were continuously enrolled and randomly divided into two groups including training and testing sets. A total of 8 ML models, including random forest (RF), Naïve Bayes, decision tree, K-nearest neighbors, logistic regression, multi-layer perceptron, support vector machine, and gradient boosting decision tree were developed based on the training set to diagnose APE. Thereafter, the model with the best diagnostic performance was selected and evaluated against the current clinical assessment strategies, including the Wells score, revised Geneva score, and Years algorithm. Eventually, the ML model was internally validated to assess the diagnostic performance using receiver operating characteristic (ROC) analysis. RESULTS The ML models were constructed using eight clinical features, including D-dimer, cardiac troponin T (cTNT), arterial oxygen saturation, heart rate, chest pain, lower limb pain, hemoptysis, and chronic heart failure. Among eight ML models, the RF model achieved the best performance with the highest area under the curve (AUC) (AUC = 0.774). Compared to the current clinical assessment strategies, the RF model outperformed the Wells score ( P = 0.030) and was not inferior to any other clinical probability assessment strategy. The AUC of the RF model for diagnosing APE onset in internal validation set was 0.726. CONCLUSIONS Based on RF algorithm, a novel prediction model was finally constructed for APE diagnosis. When compared to the current clinical assessment strategies, the RF model achieved better diagnostic efficacy and accuracy. Therefore, the ML algorithm can be a useful tool in assisting with the diagnosis of APE.
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Affiliation(s)
- Linfeng Xi
- Capital Medical University, Beijing 100069, China
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences; Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing 100029, China
| | - Han Kang
- Institute of Advanced Research, Infervision Medical Technology Co., Ltd., Beijing 100025, China
| | - Mei Deng
- Department of Radiology, China-Japan Friendship Hospital, Beijing 100029, China
- Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Wenqing Xu
- Department of Radiology, Peking University China-Japan Friendship School of Clinical Medicine, Beijing 100191, China
| | - Feiya Xu
- Capital Medical University, Beijing 100069, China
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences; Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing 100029, China
| | - Qian Gao
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences; Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing 100029, China
| | - Wanmu Xie
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences; Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing 100029, China
| | - Rongguo Zhang
- Institute of Advanced Research, Infervision Medical Technology Co., Ltd., Beijing 100025, China
| | - Min Liu
- Department of Radiology, China-Japan Friendship Hospital, Beijing 100029, China
| | - Zhenguo Zhai
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences; Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing 100029, China
| | - Chen Wang
- Capital Medical University, Beijing 100069, China
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences; Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing 100029, China
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Gianni F, Bonzi M, Jachetti A, Solbiati M, Dreon G, Colombo G, Colombo G, Russo A, Furlan L, Casazza G, Costantino G. How to recognize pulmonary embolism in syncope patients: A simple rule. Eur J Intern Med 2024; 121:121-126. [PMID: 37945410 DOI: 10.1016/j.ejim.2023.10.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 10/18/2023] [Accepted: 10/27/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Syncope can be the presenting symptom of Pulmonary Embolism (PE). It is not known wether using a standardized algorithm to rule-out PE in all patients with syncope admitted to the Emergency Departments (ED) is of value or can lead to overdiagnosis and overtreatment. METHODS We tested if simple anamnestic and clinical parameters could be used as a rule to identify patients with syncope and PE in a multicenter observational study. The rule's sensitivity was tested on a cohort of patients that presented to the ED for syncopal episodes caused by PE. The clinical impact of the rule was assessed on a population of consecutive patients admitted for syncope in the ED. RESULTS Patients were considered rule-positive in the presence of any of the following: hypotension, tachycardia, peripheral oxygen saturation ≤ 93 % (SpO2), chest pain, dyspnea, recent history of prolonged bed rest, clinical signs of deep vein thrombosis, history of previous venous thrombo-embolism and active neoplastic disease. The sensitivity of the rule was 90.3 % (95 % CI: 74.3 % to 98.0 %). The application of the rule to a population of 217 patients with syncope would have led to a 70 % reduction in the number of subjects needing additional diagnostic tests to exclude PE. CONCLUSIONS Most patients with syncope due to PE present with anamnestic and clinical features indicative of PE diagnosis. A clinical decision rule can be used to identify patients who would benefit from further diagnostic tests to exclude PE, while reducing unnecessary exams that could lead to over-testing and over-diagnosis.
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Affiliation(s)
- Francesca Gianni
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, UOC Pronto Soccorso, Milan, Italy; Dipartimento di Scienze Cliniche e di Comunità, Università degli Studi di Milano, Milan, Italy
| | - Mattia Bonzi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, UOC Pronto Soccorso, Milan, Italy
| | - Alessandro Jachetti
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, UOC Pronto Soccorso, Milan, Italy
| | - Monica Solbiati
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, UOC Pronto Soccorso, Milan, Italy; Dipartimento di Scienze Cliniche e di Comunità, Università degli Studi di Milano, Milan, Italy
| | - Giulia Dreon
- Scuola di Specializzazione in Medicina di Emergenza-Urgenza, Università degli Studi di Milano, Milan, Italy
| | - Giorgio Colombo
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, UOC Pronto Soccorso, Milan, Italy
| | - Giulia Colombo
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, UOC Pronto Soccorso, Milan, Italy
| | - Antonio Russo
- Epidemiology Unit, Agency for Health Protection of Milan, Italy
| | - Ludovico Furlan
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, UOC Pronto Soccorso, Milan, Italy; Dipartimento di Scienze Cliniche e di Comunità, Università degli Studi di Milano, Milan, Italy
| | - Giovanni Casazza
- Dipartimento di Scienze Cliniche e di Comunità, Università degli Studi di Milano, Milan, Italy; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giorgio Costantino
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, UOC Pronto Soccorso, Milan, Italy; Dipartimento di Scienze Cliniche e di Comunità, Università degli Studi di Milano, Milan, Italy.
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Tiratrakoonseree T, Charoenpichitnun S, Natesirinilkul R, Songthawee N, Komvilaisak P, Pongphitcha P, Vaewpanich J, Sirachainan N. Clinical prediction tool to identify children at risk of pulmonary embolism. Thromb Res 2024; 234:151-157. [PMID: 38241765 DOI: 10.1016/j.thromres.2024.01.006] [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: 09/25/2023] [Revised: 11/26/2023] [Accepted: 01/08/2024] [Indexed: 01/21/2024]
Abstract
INTRODUCTION The diagnosis of pediatric pulmonary embolism (PE) is often delayed due to non-specific symptoms, and clinical prediction tools designed for adults are unsuitable for children. This study aimed to create a PE predictive model and to evaluate the reported tools in the Thai pediatric population. MATERIALS AND METHODS A multi-center retrospective study from 4 university hospitals included children ≤18 years of age undergoing computed tomography pulmonary angiogram from 2000 to 2020 with the suspicion of PE. Patients' clinical presentations and risk factors of venous thromboembolism (VTE) were compared between the PE-positive and PE-negative groups. Significant risk factors from univariate and multivariate logistic regression were included to create a clinical prediction tool. The performance of the model was demonstrated by sensitivity, specificity, area under the curve (AUC), Hosmer Lemeshow test, ratio of observed and expected outcomes and bootstrapping. RESULTS Of the 104 patients included, 43 (41.3 %) were grouped as PE-positive and 61 (58.7 %) as PE-negative. Five parameters, including congenital heart disease/pulmonary surgery, known thrombophilia, previous VTE, nephrotic syndrome and chest pain showed significant differences between the two groups. Score ≥ 2 yielded a 74.4 % sensitivity and a 75.4 % specificity with an AUC of the model of 0.809. The model performance and validation results were within satisfactory ranges. CONCLUSION The study created a clinical prediction tool indicating the likelihood of PE among Thai children. A score ≥2 was suggestive of PE.
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Affiliation(s)
| | - Suwanat Charoenpichitnun
- Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; Princess Srisavangavadhana College of Medicine, Chulabhorn Royal Academy, Bangkok, Thailand
| | | | - Natsaruth Songthawee
- Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Patcharee Komvilaisak
- Department of Pediatrics, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Pongpak Pongphitcha
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Jarin Vaewpanich
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nongnuch Sirachainan
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
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Puchades R, Tung-Chen Y, Salgueiro G, Lorenzo A, Sancho T, Fernández Capitán C. Artificial intelligence for predicting pulmonary embolism: A review of machine learning approaches and performance evaluation. Thromb Res 2024; 234:9-11. [PMID: 38113607 DOI: 10.1016/j.thromres.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 12/02/2023] [Accepted: 12/05/2023] [Indexed: 12/21/2023]
Affiliation(s)
- Ramón Puchades
- Internal Medicine Service, Thromboembolic Disease Unit, La Paz University Hospital, Madrid, Spain.
| | - Yale Tung-Chen
- Internal Medicine Service, Thromboembolic Disease Unit, La Paz University Hospital, Madrid, Spain
| | - Giorgina Salgueiro
- Internal Medicine Service, Thromboembolic Disease Unit, La Paz University Hospital, Madrid, Spain
| | - Alicia Lorenzo
- Internal Medicine Service, Thromboembolic Disease Unit, La Paz University Hospital, Madrid, Spain
| | - Teresa Sancho
- Internal Medicine Service, Thromboembolic Disease Unit, La Paz University Hospital, Madrid, Spain
| | - Carmen Fernández Capitán
- Internal Medicine Service, Thromboembolic Disease Unit, La Paz University Hospital, Madrid, Spain
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Millington SJ, Aissaoui N, Bowcock E, Brodie D, Burns KEA, Douflé G, Haddad F, Lahm T, Piazza G, Sanchez O, Savale L, Vieillard-Baron A. High and intermediate risk pulmonary embolism in the ICU. Intensive Care Med 2024; 50:195-208. [PMID: 38112771 DOI: 10.1007/s00134-023-07275-6] [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: 09/14/2023] [Accepted: 11/11/2023] [Indexed: 12/21/2023]
Abstract
Pulmonary embolism (PE) is a common and important medical emergency, encountered by clinicians across all acute care specialties. PE is a relatively uncommon cause of direct admission to the intensive care unit (ICU), but these patients are at high risk of death. More commonly, patients admitted to ICU develop PE as a complication of an unrelated acute illness. This paper reviews the epidemiology, diagnosis, risk stratification, and particularly the management of PE from a critical care perspective. Issues around prevention, anticoagulation, fibrinolysis, catheter-based techniques, surgical embolectomy, and extracorporeal support are discussed.
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Affiliation(s)
- Scott J Millington
- Critical Care, The University of Ottawa/The Ottawa Hospital, Ottawa, ON, Canada
| | - Nadia Aissaoui
- Service de Médecine Intensive-Réanimation, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP). Centre & Université Paris Cité, Paris, France
| | - Emma Bowcock
- Department of Intensive Care, Nepean Hospital, University of Sydney, Sydney, Australia
| | - Daniel Brodie
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Karine E A Burns
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada
- Li Ka Shing Knowledge Institute, Unity Health Toronto-St. Michael's Hospital, Toronto, Canada
| | - Ghislaine Douflé
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Canada
| | - François Haddad
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Cardiovascular Institute, Stanford University, Stanford, CA, USA
- Vera Moulton Wall Center for Pulmonary Vascular Disease at Stanford University, Stanford, CA, USA
| | - Tim Lahm
- Pulmonary Sciences and Critical Care Medicine, National Jewish Health, University of Colorado, Rocky Mountain Regional VA Medical Center, Denver, CO, USA
| | - Gregory Piazza
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Olivier Sanchez
- Service de pneumologie et soins intensifs, Hopital Européen Georges Pompidou, APHP, Paris, France
- INSERM UMR S 1140, Innovative Therapies in Hemostasis, Université Paris Cité, Paris, France
| | - Laurent Savale
- Department of Respiratory and Intensive Care Medicine, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Antoine Vieillard-Baron
- Medical and Surgical ICU, University Hospital Ambroise Pare, GHU Paris-Saclay, APHP, Boulogne-Billancourt, France.
- Inserm U1018, CESP, Universite Versailles Saint-Quentin en Yvelines, Guyancourt, France.
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Bertsch T, Behringer W, Blaschke S, Body R, Davidson S, Müller-Olling M, Guo G, Rieger A, Wahl A, Horner D, Sun Y, Turnes L, Sonner U, Hoffmann M. Deep vein thrombosis and pulmonary embolism: a prospective, observational study to evaluate diagnostic performance of the Tina-quant D-Dimer Gen.2 assay. Front Cardiovasc Med 2023; 10:1142465. [PMID: 38169956 PMCID: PMC10759223 DOI: 10.3389/fcvm.2023.1142465] [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: 01/11/2023] [Accepted: 11/17/2023] [Indexed: 01/05/2024] Open
Abstract
Background D-Dimer testing is a diagnostic tool for exclusion of deep vein thrombosis (DVT) and pulmonary embolism (PE). This study evaluated the diagnostic performance of the Tina-quant® D-Dimer Gen.2 assay (Roche Diagnostics International Ltd, Rotkreuz, Switzerland) in patients with low/intermediate pre-test probability of DVT/PE using standard, age-, and clinical probability-adjusted cut-offs. Methods In this prospective, observational, multicenter study (July 2017-August 2019), plasma samples were collected from hospital emergency departments and specialist referral centers. DVT/PE was diagnosed under hospital standard procedures and imaging protocols. A standard D-dimer cut-off of 0.5 µg fibrinogen equivalent units (FEU)/ml was combined with the three-level Wells score; cut-offs adjusted for age (age × 0.01 µg FEU/ml for patients >50 years) and clinical probability (1 µg FEU/ml for low probability) were also evaluated. An assay comparison was conducted in a subset of samples using the Tina-quant D-Dimer Gen.2 assay and the previously established routine laboratory assay, STA-Liatest D-Di Plus assay (Stago Deutschland GmbH, Düsseldorf, Germany). Results 2,897 patients were enrolled; 2,516 completed the study (DVT cohort: 1,741 PE cohort: 775). Clinical assessment plus D-dimer testing using the standard cut-off resulted in 317 (DVT) and 230 (PE) false positives, and zero (DVT) and one (PE) false negatives. Negative predictive value (NPV) was 100.0% (95% confidence interval [CI]: 99.7%-100.0%) and 99.8% (95% CI: 98.8%-100.0%) for DVT and PE, respectively. After age-adjustment, NPV was 99.9% (95% CI: 99.6%-100.0%) and 99.1% (95% CI: 97.8-99.7) for DVT and PE, respectively. False positive rates decreased (>50%) in clinical probability-adjusted analyses vs. primary analysis. In the assay comparison, the performances of the two assays were comparable. Conclusion The Tina-quant D-Dimer Gen.2 assay and standard D-dimer cut-off level combined with the three-level Wells score accurately identified patients with a very low probability of DVT/PE.
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Affiliation(s)
- Thomas Bertsch
- Institute of Clinical Chemistry, Laboratory Medicine and Transfusion Medicine, Nuremberg General Hospital, Paracelsus Medical University, Nuremberg, Germany
| | - Wilhelm Behringer
- Department of Emergency Medicine, Faculty of Medicine, University of Jena, Jena, Germany
| | - Sabine Blaschke
- Emergency Department, University Medical Center Göttingen, Göttingen, Germany
| | - Richard Body
- Division of Cardiovascular Sciences, Core Technology Facility, University of Manchester, Manchester, United Kingdom
- Emergency Department, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Simon Davidson
- Roche Diagnostics International Ltd, Rotkreuz, Switzerland
| | | | - Ge Guo
- Roche Diagnostics, Indianapolis, IN, United States
| | | | | | - Daniel Horner
- Emergency Department, Salford Royal NHS Foundation Trust, Salford, United Kingdom
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, United Kingdom
| | - Yuli Sun
- Roche Diagnostics GmbH, Penzberg, Germany
| | - Lucia Turnes
- Agent Representing Roche Diagnostics GmbH, Penzberg, Germany
| | - Ulrich Sonner
- Agent Representing Roche Diagnostics GmbH, Penzberg, Germany
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Kasanga S, Khashan A, Salik A, Aboshehata AM, Casillas S, Islam M. Low Risk Meets High Stakes: Unraveling the Mystery of Low D-dimer Pulmonary Embolism. Cureus 2023; 15:e51045. [PMID: 38264382 PMCID: PMC10805402 DOI: 10.7759/cureus.51045] [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] [Accepted: 12/24/2023] [Indexed: 01/25/2024] Open
Abstract
Pulmonary embolisms (PEs) are potentially life-threatening emergencies that carry significant morbidity and mortality. Advances in treatment options and the safety of existing procedures have effectively reduced the long-term and short-term effects of the condition. Therefore, it is important to make an early diagnosis so that treatment options can be thoroughly explored. The D-dimer is an important tool in the early diagnosis of PEs. It is especially useful in ruling out the diagnosis in patients with a low to moderate suspicion of the disease. We present a case of a 22-year-old male who presented with exertional dyspnea, congestion, and rhinorrhea for one day and was noted to have persistent hypoxia and tachycardia. The influenza test was positive, and he was started on oseltamivir. Due to persistent hypoxia, a CT pulmonary angiogram was ordered and revealed filling defects in the left lower lobe segmental vessels suggestive of PE, as well as multifocal multilobar bilateral ground-glass opacities. He was initially treated with a heparin drip and subsequently switched to eliquis. After a significant improvement in his hypoxia, he was discharged home for outpatient follow-up, including a hypercoagulable workup. This case demonstrates that despite the usefulness of the D-dimer as a diagnostic tool for PEs, it cannot solely or fully replace the full gamut of screening tools used to determine the risk of PE. Although rare, false-negative scores do occur; therefore, the tool should always be used in conjunction with other scoring systems, physician gestalt, and within the specific clinical context.
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Affiliation(s)
- Sadat Kasanga
- Internal Medicine, Raritan Bay Medical Center, Perth Amboy, USA
| | | | - Ahsan Salik
- Internal Medicine, Raritan Bay Medical Center, Perth Amboy, USA
| | | | | | - Mohammed Islam
- Internal Medicine, Raritan Bay Medical Center, Perth Amboy, USA
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Falster C, Hellfritzsch M, Gaist TA, Brabrand M, Bhatnagar R, Nybo M, Andersen NH, Egholm G. Comparison of international guideline recommendations for the diagnosis of pulmonary embolism. Lancet Haematol 2023; 10:e922-e935. [PMID: 37804848 DOI: 10.1016/s2352-3026(23)00181-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 06/09/2023] [Accepted: 06/16/2023] [Indexed: 10/09/2023]
Abstract
Pulmonary embolism is one of the leading causes of death due to cardiovascular disease. Timely diagnosis is crucial, but challenging, as the clinical presentation of pulmonary embolism is unspecific and easily mistaken for other common medical emergencies. Clinical prediction rules and D-dimer measurement allow stratification of patients into groups of expected prevalence and are key elements in adequate selection of patients for diagnostic imaging; however, the strengths and weaknesses of the multiple proposed prediction rules, when to measure D-dimer, and which cutoff to apply might be elusive to a significant proportion of physicians. 13 international guidelines authored by medical societies or expert author groups provide recommendations on facets of the diagnostic investigations in suspected pulmonary embolism, some of which are hallmarked by pronounced heterogeneity. This Review summarises key recommendations of each guideline, considers the most recent evidence on the topic, compares guideline recommendations on each facet of the diagnosis of pulmonary embolism, and provides a synthesis on the most common recommendations.
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Affiliation(s)
- Casper Falster
- Odense Respiratory Research Unit, University of Southern Denmark, Odense, Denmark; Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark.
| | - Maja Hellfritzsch
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Danish Society of Thrombosis and Hemostasis, Roskilde, Denmark
| | | | - Mikkel Brabrand
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark; Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Rahul Bhatnagar
- Respiratory Medicine Department, North Bristol National Health Service Trust, Southmead Hospital, Bristol, UK; Academic Respiratory Unit, University of Bristol, Bristol, UK
| | - Mads Nybo
- Department of Clinical Biochemistry, Odense University Hospital, Odense, Denmark
| | | | - Gro Egholm
- Department of Cardiology, Odense University Hospital, Odense, Denmark
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11
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Neumann I, Izcovich A, Aguilar R, Basantes GL, Casais P, Colorio CC, Guillermo Esposito MC, García Lázaro PP, Pereira J, Meillon García LA, Rezende SM, Serrano JC, Tejerina Valle ML, Altuna D, Zúñiga P, Vera F, Karzulovic L, Schünemann HJ. American Society of Hematology, ABHH, ACHO, Grupo CAHT, Grupo CLAHT, SAH, SBHH, SHU, SOCHIHEM, SOMETH, Sociedad Panamena de Hematología, Sociedad Peruana de Hematología, and SVH 2023 guidelines for diagnosis of venous thromboembolism and for its management in special populations in Latin America. Blood Adv 2023; 7:3005-3021. [PMID: 36929813 PMCID: PMC10320207 DOI: 10.1182/bloodadvances.2021006534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 02/28/2023] [Accepted: 02/28/2023] [Indexed: 03/18/2023] Open
Abstract
Implementation of international guidelines in Latin American settings requires additional considerations (ie, values and preferences, resources, accessibility, feasibility, and impact on health equity). The purpose of this guideline is to provide evidence-based recommendations about the diagnosis of venous thromboembolism (VTE) and its management in children and during pregnancy. We used the GRADE ADOLOPMENT method to adapt recommendations from 3 American Society of Hematology (ASH) VTE guidelines (diagnosis of VTE, VTE in pregnancy, and VTE in the pediatric population). ASH and 12 local hematology societies formed a guideline panel comprising medical professionals from 10 countries in Latin America. Panelists prioritized 10 questions about the diagnosis of VTE and 18 questions about its management in special populations that were relevant for the Latin American context. A knowledge synthesis team updated evidence reviews of health effects conducted for the original ASH guidelines and summarized information about factors specific to the Latin American context. In comparison with the original guideline, there were significant changes in 2 of 10 diagnostic recommendations (changes in the diagnostic algorithms) and in 9 of 18 management recommendations (4 changed direction and 5 changed strength). This guideline ADOLOPMENT project highlighted the importance of contextualizing recommendations in other settings based on differences in values, resources, feasibility, and health equity impact.
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Affiliation(s)
- Ignacio Neumann
- School of Medicine, Universidad San Sebastian, Santiago, Chile
| | | | - Ricardo Aguilar
- Servicio de Hematología, Complejo Hospitalario Dr. Arnulfo Arias Madrid, Panama City, Panama
| | | | - Patricia Casais
- Epidemiología Clínica y Evidencia, Instituto de Investigaciones en Salud Pública, Universidad de Buenos Aires, Buenos Aires, Argentina
- Centro de Hematología Pavlovsky, Buenos Aires, Argentina
| | | | | | - Pedro P. García Lázaro
- Faculty of Medicine, Universidad Privada Antenor Orrego, Trujillo, Peru
- Hospital Especializado Víctor Lazarte Echegaray, Trujillo, Peru
| | - Jaime Pereira
- Department of Hematology and Oncology, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Suely Meireles Rezende
- Department of Internal Medicine, Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | | | - Diana Altuna
- Pediatric Oncology and Hematology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Pamela Zúñiga
- Department of Hematology and Oncology, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Felipe Vera
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Lorena Karzulovic
- Department of Pediatrics, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Holger J. Schünemann
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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12
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Zheng J, Han M, Chen J, Deng MM, Luo G. Predictive value of D-dimer and fibrinogen degradation product for splanchnic vein thrombosis in patients with severe acute pancreatitis: a single-center retrospective study. Scand J Gastroenterol 2023; 58:1166-1172. [PMID: 37221650 DOI: 10.1080/00365521.2023.2215367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 05/14/2023] [Indexed: 05/25/2023]
Abstract
BACKGROUND AND AIM Early diagnosis of splanchnic vein thrombosis (SVT) after severe acute pancreatitis (SAP) remains difficult because of its insidious onset. Common serum markers for thrombosis such as D-dimer (D-D) have lost their diagnostic value due to their elevation in non-thrombotic patients with SAP. The aim of this study is to predict SVT after SAP using common serum indicators of thrombosis by establishing a new cut-off value. METHODS 177 SAP patients were included in a retrospective cohort study from September 2019 to September 2021. Patient demographics, dynamic changes of coagulation and fibrinolysis indicators were collected. Univariate analyses and binary logistic regression analyses were applied to assess potential risk factors for the development of SVT in SAP patients. A receiver operating characteristic (ROC) curve was generated to assess the predictive value of independent risk factors. Moreover, clinical complications and outcomes were compared between two groups. RESULTS Among 177 SAP patients, 32 (18.1%) developed SVT. The most common cause of SAP was biliary (49.8%), followed by hypertriglyceridemia (21.5%). Multivariate logistic regression analyses showed that D-D (OR, 1.135; 95%CI, 1.043-1.236; p = 0.003) and fibrinogen degradation product (FDP) (OR, 1.037; 95%CI, 1.015-1.060; p = 0.001) were independent risk factors for SVT development in patients with SAP. The area under ROC curve for D-D was 0.891 (p = 0.003, sensitivity= 95.3%, specificity = 74.1%) at a cut-off value of 6.475, and the area under ROC curve for FDP was 0.858 (p = 0.001, sensitivity = 89.4%, specificity = 72.4%) at a cut-off value of 23.155. CONCLUSION D-D and FDP are significant independent risk factors with high predictive value for SVT in patients with SAP.
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Affiliation(s)
- Jie Zheng
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Ming Han
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Jie Chen
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Ming Ming Deng
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Gang Luo
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
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13
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Ramírez Cervantes KL, Mora E, Campillo Morales S, Huerta Álvarez C, Marcos Neira P, Nanwani Nanwani KL, Serrano Lázaro A, Silva Obregón JA, Quintana Díaz M. A Clinical Prediction Rule for Thrombosis in Critically Ill COVID-19 Patients: Step 1 Results of the Thromcco Study. J Clin Med 2023; 12:jcm12041253. [PMID: 36835788 PMCID: PMC9966844 DOI: 10.3390/jcm12041253] [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: 12/04/2022] [Revised: 02/01/2023] [Accepted: 02/02/2023] [Indexed: 02/09/2023] Open
Abstract
The incidence of thrombosis in COVID-19 patients is exceptionally high among intensive care unit (ICU)-admitted individuals. We aimed to develop a clinical prediction rule for thrombosis in hospitalized COVID-19 patients. Data were taken from the Thromcco study (TS) database, which contains information on consecutive adults (aged ≥ 18) admitted to eight Spanish ICUs between March 2020 and October 2021. Diverse logistic regression model analysis, including demographic data, pre-existing conditions, and blood tests collected during the first 24 h of hospitalization, was performed to build a model that predicted thrombosis. Once obtained, the numeric and categorical variables considered were converted to factor variables giving them a score. Out of 2055 patients included in the TS database, 299 subjects with a median age of 62.4 years (IQR 51.5-70) (79% men) were considered in the final model (SE = 83%, SP = 62%, accuracy = 77%). Seven variables with assigned scores were delineated as age 25-40 and ≥70 = 12, age 41-70 = 13, male = 1, D-dimer ≥ 500 ng/mL = 13, leukocytes ≥ 10 × 103/µL = 1, interleukin-6 ≥ 10 pg/mL = 1, and C-reactive protein (CRP) ≥ 50 mg/L = 1. Score values ≥28 had a sensitivity of 88% and specificity of 29% for thrombosis. This score could be helpful in recognizing patients at higher risk for thrombosis, but further research is needed.
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Affiliation(s)
- Karen L. Ramírez Cervantes
- Patient Blood Management Research Group, Hospital La Paz Institute for Health Research, 28040 Madrid, Spain
- Correspondence:
| | - Elianne Mora
- Department of Statistics, Charles III University of Madrid, 28903 Getafe, Spain
| | - Salvador Campillo Morales
- Patient Blood Management Research Group, Hospital La Paz Institute for Health Research, 28040 Madrid, Spain
| | - Consuelo Huerta Álvarez
- Department of Public Health & Maternal and Child Health, Faculty of Medicine, Complutense University of Madrid, 28040 Madrid, Spain
| | - Pilar Marcos Neira
- Intensive Care Unit, Hospital Germans Trias i Pujol, 08916 Badalona, Spain
| | | | | | | | - Manuel Quintana Díaz
- Patient Blood Management Research Group, Hospital La Paz Institute for Health Research, 28040 Madrid, Spain
- Intensive Care Unit, La Paz University Hospital, 28040 Madrid, Spain
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14
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Zhu N, Zhang L, Gong S, Luo Z, He L, Wang L, Qiu F, Huang W, Cao C. Derivation and External Validation of a Risk Prediction Model for Pulmonary Embolism in Patients With Lung Cancer: A Large Retrospective Cohort Study. Clin Appl Thromb Hemost 2023; 29:10760296231151696. [PMID: 36683414 PMCID: PMC9893058 DOI: 10.1177/10760296231151696] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
OBJECTIVE To investigate the risk factors of pulmonary embolism in patients with lung cancer and develop and validate a novel nomogram scoring system-based prediction model. METHOD We retrospectively analyzed the clinical data and laboratory characteristics of 900 patients with lung cancer who were treated, including patients with lung cancer without pulmonary embolism (LC) and patients with lung cancer with pulmonary embolism (LC + PE). The patients were randomly divided into derivation and internal validation groups in a 7:3 ratio. Using logistic regression analysis, a diagnostic model of the nomogram scoring system was developed by incorporating selected variables in the derivation group and validated in the internal and external validation groups (n = 108). RESULT Seven variables (adenocarcinoma, stage III-IV LC, indwelling central venous catheter, chemotherapy, and the levels of serum albumin, hemoglobin, and D-dimer) were identified as valuable parameters for developing the novel nomogram diagnostic model for differentiating patients with LC and LC + PE. The scoring system demonstrated good diagnostic performance in the derivation (area under the curve [AUC]; 95% confidence interval [CI], 0.918; 0.893, 0.943; sensitivity, 88.5%; specificity, 80.5%), internal validation (AUC; 95% CI, 0.921; 0.884, 0.958; sensitivity, 90.5%; specificity, 80.4%), and external validation (AUC; 95% CI, 0.929; 0.875, 0.983; sensitivity; 85.0%; specificity; 87.5%) groups. CONCLUSION In this study, we constructed and validated a nomogram scoring system based on 7 clinical parameters. The scoring system exhibits good accuracy and discrimination between patients with LC and LC + PE and can effectively predict the risk of PE in patients with LC.
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Affiliation(s)
- Ning Zhu
- Department of Respiratory and Critical Care Medicine, Ningbo First Hospital, Ningbo, China,Chao Cao, Department of Respiratory Medicine, Ningbo First Hospital, 59 Liuting Road, Ningbo, Zhejiang 315010, China.
| | - Lei Zhang
- Department of Respiratory and Critical Care Medicine, The Affiliated People Hospital of Ningbo University, Ningbo, China
| | - Shengping Gong
- Department of Chemoradio-Oncology, Ningbo First Hospital, Ningbo, China
| | - Zhuanbo Luo
- Department of Respiratory and Critical Care Medicine, Ningbo First Hospital, Ningbo, China
| | - Lei He
- Department of Respiratory and Critical Care Medicine, Ningbo First Hospital, Ningbo, China
| | - Linfeng Wang
- Department of Respiratory and Critical Care Medicine, Ningbo First Hospital, Ningbo, China
| | - Feng Qiu
- Department of Respiratory and Critical Care Medicine, Ningbo First Hospital, Ningbo, China
| | - Weina Huang
- Department of Respiratory and Critical Care Medicine, Ningbo First Hospital, Ningbo, China
| | - Chao Cao
- Department of Respiratory and Critical Care Medicine, Ningbo First Hospital, Ningbo, China
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15
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Falster C, Egholm G, Wiig R, Poulsen MK, Møller JE, Posth S, Brabrand M, Laursen CB. Diagnostic Accuracy of a Bespoke Multiorgan Ultrasound Approach in Suspected Pulmonary Embolism. Ultrasound Int Open 2023; 8:E59-E67. [PMID: 36726389 PMCID: PMC9886498 DOI: 10.1055/a-1971-7454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 10/23/2022] [Indexed: 01/18/2023] Open
Abstract
Purpose The aims of this study were to prospectively assess the diagnostic accuracy of a bespoke multiorgan point-of-care ultrasound approach for suspected pulmonary embolism and evaluate if this model allows reduced referral to further radiation diagnostics while maintaining safety standards. Materials and Methods Patients with suspected pulmonary embolism referred for CT pulmonary angiography or ventilation/perfusion scintigraphy were included as a convenience sample. All patients were subject to blinded ultrasound investigation with cardiac, lung, and deep venous ultrasound. The sensitivity and specificity of applied ultrasound signs and the hypothetical reduction in the need for further diagnostic workup were calculated. Results 75 patients were prospectively enrolled. The Wells score was below 2 in 48 patients, between 2 and 6 in 24 patients, and above 6 in 3 patients. The prevalence of pulmonary embolism was 28%. The most notable ultrasound signs were presence of a deep venous thrombus, at least two hypoechoic pleural-based lesions, the D-sign, the 60/60-sign, and a visible right ventricular thrombus which all had a specificity of 100%. Additionally, a multiorgan ultrasound investigation with no findings compatible with pulmonary embolism yielded a sensitivity of 95.2% (95%CI: 76.2-99.9). CT or scintigraphy could be safely avoided in 70% of cases (95%CI: 63.0-83.1%). Conclusion The findings of our study suggest that implementation of a multiorgan ultrasound assessment in patients with suspected pulmonary embolism may safely reduce the need for CT or scintigraphy by confirming or dismissing the suspicion.
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Affiliation(s)
- Casper Falster
- Department of Respiratory Medicine, Odense University Hospital, Odense,
Denmark,Odense Respiratory Research Unit (ODIN), Department of Clinical
Research, University of Southern Denmark, Odense, Denmark,OPEN, Open Patient data Explorative Network, Odense University
Hospital, Odense, Denmark,Correspondence Dr. Casper Falster Odense
University HospitalDepartment of respiratory
medicineKløvervænget
25000
OdenseDenmark+4560139562
| | - Gro Egholm
- Department of Cardiology, Odense University Hospital, Odense,
Denmark
| | - Rune Wiig
- Odense Respiratory Research Unit (ODIN), Department of Clinical
Research, University of Southern Denmark, Odense, Denmark
| | | | | | - Stefan Posth
- Department of Emergency Medicine, Odense University Hospital, Odense,
Denmark
| | - Mikkel Brabrand
- Department of Emergency Medicine, Odense University Hospital, Odense,
Denmark
| | - Christian Borbjerg Laursen
- Department of Respiratory Medicine, Odense University Hospital, Odense,
Denmark,Odense Respiratory Research Unit (ODIN), Department of Clinical
Research, University of Southern Denmark, Odense, Denmark
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16
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Hobohm L, Sagoschen I, Barco S, Farmakis IT, Fedeli U, Koelmel S, Gori T, Espinola-Klein C, Münzel T, Konstantinides S, Keller K. COVID-19 infection and its impact on case fatality in patients with pulmonary embolism. Eur Respir J 2023; 61:13993003.00619-2022. [PMID: 35981745 PMCID: PMC9411730 DOI: 10.1183/13993003.00619-2022] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 07/20/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although a high prevalence of pulmonary embolism (PE) has been reported in association with coronavirus disease 2019 (COVID-19) in critically ill patients, nationwide data on the outcome of hospitalised patients with COVID-19 and PE are still limited. Thus, we investigated seasonal trends and predictors of in-hospital death in patients with COVID-19 and PE in Germany. METHODS We used a German nationwide inpatient sample to analyse data on hospitalisations among COVID-19 patients with and without PE during 2020, and to detect changes in PE prevalence and case fatality in comparison with 2019. RESULTS We analysed 176 137 COVID-19 hospitalisations in 2020; PE was recorded in 1.9% (n=3362) of discharge certificates. Almost one-third of patients with COVID-19 and PE died during the in-hospital course (28.7%) compared with COVID-19 patients without PE (17.7%). Between 2019 and 2020, numbers of PE-related hospitalisations were largely unchanged (98 485 versus 97 718), whereas the case fatality rate of PE increased slightly in 2020 (from 12.7% to 13.1%; p<0.001). Differences in case fatality were found between PE patients with and without COVID-19 in 2020 (28.7% versus 12.5%; p<0.001), corresponding to a 3.1-fold increased risk of PE-related death (OR 3.16, 95% CI 2.91-3.42; p<0.001) in the presence of COVID-19. CONCLUSIONS In Germany, the prevalence of PE events during hospitalisations was similar in 2019 and 2020. However, the fatality rate among patients with both COVID-19 and PE was substantially higher than that in those with only one of these diseases, suggesting a life-threatening additive prognostic impact of the COVID-19-PE combination.
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Affiliation(s)
- Lukas Hobohm
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
- L. Hobohm and I. Sagoschen contributed equally and share first authorship
| | - Ingo Sagoschen
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
- L. Hobohm and I. Sagoschen contributed equally and share first authorship
| | - Stefano Barco
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Ioannis T Farmakis
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
- Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ugo Fedeli
- Epidemiological Department, Azienda Zero, Padova, Italy
| | - Sebastian Koelmel
- Department of Internal Medicine, Triemli Hospital Zurich, Zurich, Switzerland
| | - Tommaso Gori
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Christine Espinola-Klein
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Thomas Münzel
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Karsten Keller
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
- Medical Clinic VII, Department of Sports Medicine, University Hospital Heidelberg, Heidelberg, Germany
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17
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Meusel M, Pätz T, Gruber K, Kupp S, Jensch PJ, Saraei R, Fürschke A, Sayk F, Eitel I, Wolfrum S. PrEdictive value of coMbined pre-test proBability and blOod gas anaLysis In pulmonary emboliSM-the EMBOLISM study. Intern Emerg Med 2022; 17:2245-2252. [PMID: 35976533 PMCID: PMC9652271 DOI: 10.1007/s11739-022-03075-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 08/02/2022] [Indexed: 11/05/2022]
Abstract
In patients with suspected pulmonary embolism (PE), the number of unnecessary computed tomography pulmonary angiography (CTPA) scans remains high, especially in patients with low pre-test probability (PTP). So far, no study showed any additional benefit of capillary blood gas analysis (BGA) in diagnostic algorithms for PE. In this retrospective analysis of patients with suspected PE and subsequent CTPA, clinical data, D-dimer levels and BGA parameters (including standardized PaO2) were analyzed. Logistic regression analyses were performed to identify independent predictors for PE and reduce unnecessary CTPA examinations in patients with low PTP according to Wells score. Of 1538 patients, PE was diagnosed in 433 patients (28.2%). The original Wells score (odds ratio: 1.381 [95% CI 1.300-1.467], p < 0.001) and standardized PaO2 (odds ratio: 0.987 [95% CI 0.978-0.996], p = 0.005) were independent predictors for PE. After cohort adjustment for low PTP a D-dimer cut-off < 1.5 mg/L (278 patients (18.1%) with 18 PE (6.5%)) was identified in which a standardized PaO2 > 65 mmHg reduced the number of unnecessary CTPA by 31.9% with a 100% sensitivity. This approach was further validated in additional 53 patients with low PTP. In this validation group CTPA examinations were reduced by 32.7%. No patient with PE was missed. With our novel algorithm combining BGA testing with low PTP according to Wells score, we were able to increase the D-Dimer threshold to 1.5 mg/L and reduce CTPA examinations by approximately 32%.
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Affiliation(s)
- Moritz Meusel
- Department of Cardiology, Angiology and Intensive Care Medicine, University Heart Center Lübeck, University Hospital Schleswig-Holstein, University of Lübeck, German Center for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.
| | - Toni Pätz
- Department of Cardiology, Angiology and Intensive Care Medicine, University Heart Center Lübeck, University Hospital Schleswig-Holstein, University of Lübeck, German Center for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Kim Gruber
- Department of Cardiology, Angiology and Intensive Care Medicine, University Heart Center Lübeck, University Hospital Schleswig-Holstein, University of Lübeck, German Center for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Sebastian Kupp
- Department of Cardiology, Angiology and Intensive Care Medicine, University Heart Center Lübeck, University Hospital Schleswig-Holstein, University of Lübeck, German Center for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Philipp-Johannes Jensch
- Department of Cardiology, Angiology and Intensive Care Medicine, University Heart Center Lübeck, University Hospital Schleswig-Holstein, University of Lübeck, German Center for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Roza Saraei
- Department of Cardiology, Angiology and Intensive Care Medicine, University Heart Center Lübeck, University Hospital Schleswig-Holstein, University of Lübeck, German Center for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Alexander Fürschke
- Department of Radiology and Nuclear Medicine, University Hospital of Schleswig Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Friedhelm Sayk
- Department of Internal Medicine I, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Ingo Eitel
- Department of Cardiology, Angiology and Intensive Care Medicine, University Heart Center Lübeck, University Hospital Schleswig-Holstein, University of Lübeck, German Center for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Sebastian Wolfrum
- Emergency Department, University Hospital Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
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18
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Piazza I, Passarella M, Fornelli V, Memaj I. YEARS rule combined with the age-adjusted D-dimer threshold in patients with suspected pulmonary embolism. Intern Emerg Med 2022; 17:2141-2142. [PMID: 35939204 DOI: 10.1007/s11739-022-03070-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 07/27/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Isabelle Piazza
- Università Degli Studi Di Milano, Milan, Italy.
- Emergency Department, ASST Papa Giovanni XXIII, Piazza OMS, 1, 24127, Bergamo, Italy.
| | - Mariele Passarella
- Università Degli Studi Di Milano, Milan, Italy
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Vincenzo Fornelli
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Irdi Memaj
- Università Degli Studi Di Milano, Milan, Italy
- Emergency Department, ASST Papa Giovanni XXIII, Piazza OMS, 1, 24127, Bergamo, Italy
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19
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Kwon H, Kim YJ, Her EJ, Chae B, Lee YS. Elevation of the D-dimer cut-off level might be applicable to rule out pulmonary embolism for active cancer patients in the emergency department. Intern Emerg Med 2022; 17:495-502. [PMID: 33837486 DOI: 10.1007/s11739-021-02730-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 03/29/2021] [Indexed: 10/21/2022]
Abstract
Recent guidelines for diagnosing acute pulmonary embolism (PE) are based on clinical decision rules and D-dimer. D-dimer measurement is recommended only for patients who are 'PE-unlikely'. We aimed to assess the current guidelines for cancer patients and to determine an optimal D-dimer cut-off level. This retrospective observational study was conducted in the emergency department of Asan Medical Center (Seoul, Korea) between 02/2017 and 09/2017 for the development cohort and between 06/2018 and 02/2019 for the validation cohort. Among adult active cancer patients with suspected PE, we included those who were 'PE-unlikely' according to Wells' criteria and who underwent D-dimer testing and computed tomographic pulmonary angiography (CTPA). A total of 498 patients (227 in the development cohort and 271 in the validation cohort) were included, and PE was diagnosed in 8.8% and 18.5% of patients, respectively. The optimal D-dimer cut-off level was 2.0 μg/mL. This elevated cut-off level showed a much higher specificity of 21.3% (95% confidence interval [CI] 16.2-27.3%) and 21.7% (95% CI 16.8-7.6%) in the development and validation sets, respectively, compared with the specificity of 4.4% (95% CI 2.3-8.1%) and 4.1% (95% CI 2.2-7.6%) using the age-adjusted cut-off. The new D-dimer cut-off value identified unnecessary CTPA for 21.3% of patients (absolute difference, 16.9%, 35 of 207) in the development cohort and 21.7% (absolute difference, 17.6%, 39 of 221) of patients in the validation cohort compared to using the standard age-adjusted cut-off. The elevated D-dimer cut-off value combined with Wells' criteria might reduce unnecessary CTPA in active cancer patients with a 'PE-unlikely' classification. Further clinical trials are warranted to improve the PE diagnostic strategy in cancer patients.
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Affiliation(s)
- Hyojeong Kwon
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Youn-Jung Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Eun-Ju Her
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Bora Chae
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Yoon-Seon Lee
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
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Eid M, Boghdady AM, Ahmed MM, Dahab LHA. Echocardiographic findings in patients with acute pulmonary embolism at Sohag University Hospitals. THE EGYPTIAN JOURNAL OF INTERNAL MEDICINE 2022; 34:21. [PMID: 35221662 PMCID: PMC8857893 DOI: 10.1186/s43162-022-00114-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 02/01/2022] [Indexed: 12/03/2022] Open
Abstract
Background Acute pulmonary thromboembolism (PTE) is one of the serious medical issues with higher prevalence and mortality rates. As mentioned in several medical reports, most of the chest pain patients, visiting the emergency departments, are usually diagnosed with either acute PTE, acute coronary syndromes, or acute aortic syndromes. The current study aimed to study the risk factors and explore the echocardiographic findings in patients with PTE. Results Forty patients with acute pulmonary embolism were enrolled in the study. Echocardiography and computed tomography pulmonary angiography (CTPA) were evaluated for all participants. The echocardiography showed that 29 patients (72.5%) had echocardiographic findings suggestive of acute PTE. Twenty-four patients (60%) had tricuspid regurge. Twenty-one patients (52.5%) had dilated right ventricle (RV). Also, 13 patients (32.5%) had an echocardiographic finding of pulmonary hypertension. Furthermore, ten patients (25%) had McConnell’s sign, and 21 patients (52.5%) had RV systolic dysfunction where only two (5%) showed RV thrombosis. Echocardiographic data of the eight high-risk patients showed that 6 patients (75%) had TR, 8 patients (100%) had dilated RV, 5 patients (62.5%) had pulmonary hypertension, 8 patients (100%) had McConnell’s sign, one patient (12.5%) had RV thrombus, and 8 patients (100%) had RV systolic dysfunction. Conclusion The results revealed that thrombus in the main pulmonary trunk was a high-risk factor for patients with acute pulmonary embolism. The current study suggested that echocardiography is an important bedside imaging tool for the diagnosis of PTE. Echocardiography could detect the tricuspid regurge, pulmonary hypertension, McConnell’s sign, RV dilatation, thrombosis, and dysfunction. Furthermore, echocardiography was considered a non-invasive test for rapid diagnosis of PTE and determining the degree of the risk category (high- or low-risk patients) specially with the presence of McConnell’s sign, dilated RV, and RV systolic dysfunction.
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Quezada-Feijoo M, Ramos M, Lozano-Montoya I, Sarró M, Cabo Muiños V, Ayala R, Gómez-Pavón FJ, Toro R. Elderly Population with COVID-19 and the Accuracy of Clinical Scales and D-Dimer for Pulmonary Embolism: The OCTA-COVID Study. J Clin Med 2021; 10:5433. [PMID: 34830715 PMCID: PMC8619636 DOI: 10.3390/jcm10225433] [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: 10/11/2021] [Revised: 11/16/2021] [Accepted: 11/17/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Elderly COVID-19 patients have a high risk of pulmonary embolism (PE), but factors that predict PE are unknown in this population. This study assessed the Wells and revised Geneva scoring systems as predictors of PE and their relationships with D-dimer (DD) in this population. METHODS This was a longitudinal, observational study that included patients ≥75 years old with COVID-19 and suspected PE. The performances of the Wells score, revised Geneva score and DD levels were assessed. The combinations of the DD level and the clinical scales were evaluated using positive rules for higher specificity. RESULTS Among 305 patients included in the OCTA-COVID study cohort, 50 had suspected PE based on computed tomography pulmonary arteriography (CTPA), and the prevalence was 5.6%. The frequencies of PE in the low-, intermediate- and high-probability categories were 5.9%, 88.2% and 5.9% for the Geneva model and 35.3%, 58.8% and 5.9% for the Wells model, respectively. The DD median was higher in the PE group (4.33 mg/L; interquartile range (IQR) 2.40-7.17) than in the no PE group (1.39 mg/L; IQR 1.01-2.75) (p < 0.001). The area under the curve (AUC) for DD was 0.789 (0.652-0.927). After changing the cutoff point for DD to 4.33 mg/L, the specificity increased from 42.5% to 93.9%. CONCLUSIONS The cutoff point DD > 4.33 mg/L has an increased specificity, which can discriminate false positives. The addition of the DD and the clinical probability scales increases the specificity and negative predictive value, which helps to avoid unnecessary invasive tests in this population.
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Affiliation(s)
- Maribel Quezada-Feijoo
- Cardiology Departament, Hospital Central de la Cruz Roja, C/Reina Victoria, 24, 28003 Madrid, Spain; (M.R.); (R.A.)
- Facultad de Medicina, Universidad Alfonso X El Sabio, Avda. De la Universidad, 1, Villanueva de la Cañada, 28691 Madrid, Spain; (I.L.-M.); (F.J.G.-P.)
| | - Mónica Ramos
- Cardiology Departament, Hospital Central de la Cruz Roja, C/Reina Victoria, 24, 28003 Madrid, Spain; (M.R.); (R.A.)
- Facultad de Medicina, Universidad Alfonso X El Sabio, Avda. De la Universidad, 1, Villanueva de la Cañada, 28691 Madrid, Spain; (I.L.-M.); (F.J.G.-P.)
| | - Isabel Lozano-Montoya
- Facultad de Medicina, Universidad Alfonso X El Sabio, Avda. De la Universidad, 1, Villanueva de la Cañada, 28691 Madrid, Spain; (I.L.-M.); (F.J.G.-P.)
- Geriatric Departament, Hospital Central de la Cruz Roja, C/Reina Victoria, 24, 28003 Madrid, Spain
| | - Mónica Sarró
- Radiology Departament, Hospital Central de La Cruz Roja, C/Reina Victoria, 24, 28003 Madrid, Spain;
| | - Verónica Cabo Muiños
- Biochemistry Laboratory, Hospital Central de la Cruz Roja, C/Reina Victoria, 24, 28003 Madrid, Spain;
| | - Rocío Ayala
- Cardiology Departament, Hospital Central de la Cruz Roja, C/Reina Victoria, 24, 28003 Madrid, Spain; (M.R.); (R.A.)
- Facultad de Medicina, Universidad Alfonso X El Sabio, Avda. De la Universidad, 1, Villanueva de la Cañada, 28691 Madrid, Spain; (I.L.-M.); (F.J.G.-P.)
| | - Francisco J. Gómez-Pavón
- Facultad de Medicina, Universidad Alfonso X El Sabio, Avda. De la Universidad, 1, Villanueva de la Cañada, 28691 Madrid, Spain; (I.L.-M.); (F.J.G.-P.)
- Geriatric Departament, Hospital Central de la Cruz Roja, C/Reina Victoria, 24, 28003 Madrid, Spain
| | - Rocío Toro
- Biomedical Research and Innovation Institute of Cádiz (INiBICA), Research Unit, Puerta del Mar University Hospital, Av/Ana de Viya 21, 11009 Cádiz, Spain;
- Medicine Department, School of Medicine, Cádiz University, Edificio Andrés Segovia 30 Floor, C/Dr Marañón S/N, 21001 Cádiz, Spain
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Innocenti F, Lazzari C, Ricci F, Paolucci E, Agishev I, Pini R. D-Dimer Tests in the Emergency Department: Current Insights. Open Access Emerg Med 2021; 13:465-479. [PMID: 34795538 PMCID: PMC8593515 DOI: 10.2147/oaem.s238696] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 10/18/2021] [Indexed: 12/24/2022] Open
Abstract
In the Emergency Medicine setting, D-dimer is currently employed in the diagnostic assessment of suspected venous thromboembolism and aortic syndrome. The nonspecific symptoms reported by patients, like chest pain, dyspnea or syncope, uncover a wide range of differential diagnosis, spanning from mild to life-threatening conditions. Therefore, we assumed the perspective of the Emergency Physician and, in this narrative review, we reported a brief presentation of the epidemiology of these symptoms and the characteristics of patients, in whom we could suspect the aforementioned pathologies. We also reported in which patients D-dimer gives useful information. In fact, when the probability of the disease is high, the D-dimer level is futile. On the contrary, given the low specificity of the test, when the probability of the disease is very low, a false-positive value of the D-dimer only increases the risk of overtesting. Patients with low to moderate probability really benefit from the D-dimer testing, in order to prevent the execution of expensive and potentially dangerous imaging tests. In the second part of the review, we focused on the prognostic value of the test in septic patients. The early prognostic stratification of septic patients remains a challenge for the Emergency Physician, in the absence of a definite biomarker or score to rely on. Therefore, we need several parameters for the early identification of patients at risk of an adverse prognosis and the D-dimer may play a role in this demanding task. SARS COVID-19 patients represent an emerging reality, where the role of the D-dimer for prognostic stratification could be relevant. In fact, in patients with severe forms of this disease, the D-dimer reaches very high values, which appear to parallel the course of respiratory failure. Whether the test may add useful information for the management of these patients remains to be determined.
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Affiliation(s)
- Francesca Innocenti
- Emergency Department High-Dependency Unit, Department of Clinical and Experimental Medicine, Careggi University Hospital, Florence, Italy
| | - Cristian Lazzari
- Emergency Department High-Dependency Unit, Department of Clinical and Experimental Medicine, Careggi University Hospital, Florence, Italy
| | - Francesca Ricci
- Emergency Department High-Dependency Unit, Department of Clinical and Experimental Medicine, Careggi University Hospital, Florence, Italy
| | - Elisa Paolucci
- Emergency Department High-Dependency Unit, Department of Clinical and Experimental Medicine, Careggi University Hospital, Florence, Italy
| | - Ilya Agishev
- Emergency Department High-Dependency Unit, Department of Clinical and Experimental Medicine, Careggi University Hospital, Florence, Italy
| | - Riccardo Pini
- Emergency Department High-Dependency Unit, Department of Clinical and Experimental Medicine, Careggi University Hospital, Florence, Italy
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23
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Bellesini M, Robert‐Ebadi H, Combescure C, Dedionigi C, Le Gal G, Righini M. D-dimer to rule out venous thromboembolism during pregnancy: A systematic review and meta-analysis. J Thromb Haemost 2021; 19:2454-2467. [PMID: 34161671 PMCID: PMC8519079 DOI: 10.1111/jth.15432] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 06/15/2021] [Accepted: 06/22/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND The usefulness of D-dimer measurement to rule out venous thromboembolism (VTE) during pregnancy is debated. OBJECTIVES We performed a systematic review and meta-analysis to investigate the safety of D-dimer to rule out acute VTE in pregnant women with suspected pulmonary embolism and/or deep vein thrombosis. METHODS Two reviewers independently identified studies through PubMed and Embase until June 2021, week 1. We supplemented our search by manually reviewing reference lists of all retrieved articles, clinicalTrials.gov, and reference literature. Prospective or retrospective studies in which a formal diagnostic algorithm was used to evaluate the ability of D-dimer to rule out VTE during pregnancy were eligible. RESULTS We identified 665 references through systematic database and additional search strategies; 45 studies were retrieved in full, of which four were included, after applying exclusion criteria. Three studies were prospective, and one had a retrospective design. The 3-month thromboembolic rate in pregnant women left untreated after a negative D-dimer was 1/312 (0.32%; 95% CI, 0.06-1.83). The pooled estimate values were 99.5% for sensitivity (95% CI, 95.0-100.0; I², 0%) and 100% for negative predictive value (95% CI, 99.19-100.0; I², 0%). The prevalence of VTE and the yield of D-dimer were 7.4% (95% CI, 3.8-12; I², 83%) and 34.2% (95% CI, 15.9-55.23; I², 89%) respectively. CONCLUSION Our results suggest that D-dimer allows to safely rule out VTE in pregnant women with suspected VTE and a disease prevalence consistent with a low/intermediate or unlikely pretest probability.
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Affiliation(s)
- Marta Bellesini
- Division of Angiology and HemostasisGeneva University Hospitals and Faculty of MedicineGenevaSwitzerland
- Department of Medicine and SurgeryResearch Center on Thromboembolic Disorders and Antithrombotic TherapiesUniversity of InsubriaVarese and ComoItaly
| | - Helia Robert‐Ebadi
- Division of Angiology and HemostasisGeneva University Hospitals and Faculty of MedicineGenevaSwitzerland
| | - Christophe Combescure
- Division of Clinical EpidemiologyDepartment of Health and Community MedicineGeneva University HospitalsGenevaSwitzerland
| | - Cristina Dedionigi
- Department of Medicine and SurgeryResearch Center on Thromboembolic Disorders and Antithrombotic TherapiesUniversity of InsubriaVarese and ComoItaly
| | - Grégoire Le Gal
- Department of MedicineOttawa Hospital Research InstituteUniversity of OttawaOttawaONCanada
| | - Marc Righini
- Division of Angiology and HemostasisGeneva University Hospitals and Faculty of MedicineGenevaSwitzerland
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24
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Cui LY, Cheng WW, Mou ZW, Xiao D, Li YY, Li YJ, Li WT, Chen ZM. Risk factors for pulmonary embolism in patients with COVID-19: a systemic review and meta-analysis. Int J Infect Dis 2021; 111:154-163. [PMID: 34418565 PMCID: PMC8372457 DOI: 10.1016/j.ijid.2021.08.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 06/12/2021] [Accepted: 08/06/2021] [Indexed: 12/28/2022] Open
Abstract
PURPOSE To detect the risk factors for pulmonary embolism (PE) in patients with COVID-19. METHODS Studies were searched for in PubMed, Cochrane Library, Web of Science, and EMBASE. Two authors independently screened articles and extracted data. The data were pooled by meta-analysis and three subgroup analyses were performed. RESULTS Of the 2210 articles identified, 27 studies were included. Pooled analysis suggested that males (odds ratio (OR) 1.49, 95% confidence interval (CI) 1.26-1.75, P = 0.000), obesity (OR 1.37, 95% CI 1.03-1.82, P = 0.033), mechanical ventilation (OR 3.34, 95% CI 1.90-5.86, P = 0.000), severe parenchymal abnormalities (OR 1.92, 95% CI 1.43-2.58, P = 0.000), ICU admission (OR 2.44, 95% CI 1.48-4.03, P = 0.000), and elevated D-dimer and white blood cell values (at two time points: hospital admission or closest to computed tomography pulmonary angiography) (P = 0.000) correlated with a risk for PE occurrence in COVID-19 patients. However, age and common comorbidities had no association with PE occurrence. Computed tomography pulmonary angiography, unclear-ratio/low-ratio, and hospitalization subgroups had consistent risk factors with all studies; however, other subgroups had fewer risk factors for PE. CONCLUSIONS Risk factors for PE in COVID-19 were different from the classic risk factors for PE and are likely to differ in diverse study populations.
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Affiliation(s)
- Li-Yan Cui
- Department of rehabilitation medicine, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Wen-Wen Cheng
- Department of Neurology, Maoming People's Hospital, Maoming, Guangdong 525000, China
| | - Zhi-Wei Mou
- Department of rehabilitation medicine, The Fifth Affiliated Hospital of Jinan University, Guangzhou, China
| | - Duan Xiao
- Department of rehabilitation medicine, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Yun-Yi Li
- Department of nephrology, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Yu-Jie Li
- Songgang People's Hospital, Baoan District, Shenzhen
| | - Wan-Ting Li
- Department of rehabilitation medicine, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Zhuo-Ming Chen
- Department of rehabilitation medicine, The First Affiliated Hospital of Jinan University, Guangzhou, China.
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25
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Hou L, Hu L, Gao W, Sheng W, Hao Z, Chen Y, Li J. Construction of a Risk Prediction Model for Hospital-Acquired Pulmonary Embolism in Hospitalized Patients. Clin Appl Thromb Hemost 2021; 27:10760296211040868. [PMID: 34558325 PMCID: PMC8495515 DOI: 10.1177/10760296211040868] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
The purpose of this study is to establish a novel pulmonary embolism (PE) risk
prediction model based on machine learning (ML) methods and to evaluate the
predictive performance of the model and the contribution of variables to the
predictive performance. We conducted a retrospective study at the Shanghai Tenth
People's Hospital and collected the clinical data of in-patients that received
pulmonary computed tomography imaging between January 1, 2014 and December 31,
2018. We trained several ML models, including logistic regression (LR), support
vector machine (SVM), random forest (RF), and gradient boosting decision tree
(GBDT), compared the models with representative baseline algorithms, and
investigated their predictability and feature interpretation. A total of 3619
patients were included in the study. We discovered that the GBDT model
demonstrated the best prediction with an area under the curve value of 0.799,
whereas those of the RF, LR, and SVM models were 0.791, 0.716, and 0.743,
respectively. The sensibilities of the GBDT, LR, RF, and SVM models were 63.9%,
68.1%, 71.5%, and 75%, respectively; the specificities were 81.1%, 66.1, 72.7%,
and 65.1%, respectively; and the accuracies were 77.8%, 66.5%, 72.5%, and 67%,
respectively. We discovered that the maximum D-dimer level contributed the most
to the outcome prediction, followed by the extreme growth rate of the plasma
fibrinogen level, in-hospital duration, and extreme growth rate of the D-dimer
level. The study demonstrates the superiority of the GBDT model in predicting
the risk of PE in hospitalized patients. However, in order to be applied in
clinical practice and provide support for clinical decision-making, the
predictive performance of the model needs to be prospectively verified.
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Affiliation(s)
- Lengchen Hou
- Shanghai Tenth People's Hospital, Shanghai, China.,*As co-first authors, the two authors have an equally important contribution to this research
| | - Longjun Hu
- Shanghai Tenth People's Hospital, Shanghai, China.,*As co-first authors, the two authors have an equally important contribution to this research
| | - Wenxue Gao
- Shanghai Tenth People's Hospital, Shanghai, China
| | - Wenbo Sheng
- Shanghai Synyi Medical Technology Co., Ltd, Shanghai, China
| | - Zedong Hao
- Shanghai Synyi Medical Technology Co., Ltd, Shanghai, China
| | - Yiwei Chen
- Shanghai Synyi Medical Technology Co., Ltd, Shanghai, China
| | - Jiyu Li
- Shanghai Tenth People's Hospital, Shanghai, China
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26
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El-Amin N, Lauzon SD, Nietert PJ, Kanter J. Which adults with sickle cell disease need an evaluation for pulmonary embolism? Br J Haematol 2021; 195:447-455. [PMID: 34472094 DOI: 10.1111/bjh.17552] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 04/19/2021] [Accepted: 04/20/2021] [Indexed: 02/02/2023]
Abstract
Individuals living with sickle cell disease (SCD) are at an increased risk of venous thrombo-embolism (VTE) including pulmonary embolisms (PEs). There is a high mortality associated with PE in individuals with SCD. It can be difficult to diagnose PE since presenting symptoms of PE often mimic those of other forms of vaso-occlusive crisis in SCD. Currently, there are no validated models for predicting PEs in patients with sickle cell disease, which often leads to frequent CT scans and exposure to harmful radiation and intravenous contrast. The aim of this study was to evaluate different host variables and potential clinical biomarkers of patients with SCD including those used in the Wells score to assess predictability for PE in order to create a more accurate diagnostic algorithm to predict PE. A retrospective chart review was performed on 349 patients with SCD who underwent testing for a PE with a CT scan of the chest. Forward and backward stepwise model selection was performed to obtain a parsimonious model of the predictors of PEs. The incidence of PE in this population was 9·7%. Of the factors evaluated for this study, the Wells score was the only one with clinical significance. A Wells score greater than 4 had a sensitivity and specificity of 72·5% and 70·1%, respectively, and a score greater than 6 had a sensitivity and specificity of 50% and 87%, respectively. The Wells score is an acceptable clinical tool which may prove useful in individuals with SCD to predict who is most likely to have a PE and therefore should undergo a CT scan. A prospective study is needed to further confirm these findings.
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Affiliation(s)
- Nadirah El-Amin
- Division of Pediatric Hematology-Oncology, Virginia Commonwealth University, Richmond, VA, USA
| | | | - Paul J Nietert
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Julie Kanter
- Division of Hematology and Oncology, University of Alabama at Birmingham, Birmingham, AL, USA
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27
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Combination of the Simplified Modified Geneva and Wells Clinical Prediction Scoring promise a good performance in pulmonary embolism diagnosis. JOURNAL OF SURGERY AND MEDICINE 2021. [DOI: 10.28982/josam.962221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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28
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Andruchow JE, Grigat D, McRae AD, Innes G, Vatanpour S, Wang D, Taljaard M, Lang E. Decision support for computed tomography in the emergency department: a multicenter cluster-randomized controlled trial. CAN J EMERG MED 2021; 23:631-640. [PMID: 34351598 DOI: 10.1007/s43678-021-00170-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 06/17/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Clinical decision support may facilitate evidence-based imaging, but most studies to date examining the impact of decision support have used non-randomized designs which limit the conclusions that can be drawn from them. This randomized trial examines if decision support can reduce computed tomography (CT) utilization for patients with mild traumatic brain injuries and suspected pulmonary embolism in the emergency department. This study was funded by a competitive public research grant and registered on ClinicalTrials.gov (NCT02410941). METHODS Emergency physicians at five urban sites were assigned to voluntary decision support for CT imaging of patients with either head injuries or suspected pulmonary embolism using a cluster-randomized design over a 1-year intervention period. The co-primary outcomes were CT head and CT pulmonary angiography utilization. CT pulmonary angiography diagnostic yield (proportion of studies diagnostic for acute pulmonary embolism) was a secondary outcome. RESULTS A total of 225 physicians were randomized and studied over a 2-year baseline and 1-year intervention period. Physicians interacted with the decision support in 38.0% and 45.0% of eligible head injury and suspected pulmonary embolism cases, respectively. A mixed effects logistic regression model demonstrated no significant impact of decision support on head CT utilization (OR 0.93, 95% CI 0.79-1.10, p = 0.31), CT pulmonary angiography utilization (OR 0.98, 95% CI 0.88-1.11, p = 0.74) or diagnostic yield (OR 1.23, 95% CI 0.96-1.65, p = 0.10). However, overall CT pulmonary diagnostic yield (17.7%) was almost three times higher than that reported by a recent large US study, suggesting that selective imaging was already being employed. CONCLUSION Voluntary decision support addressing many commonly cited barriers to evidence-based imaging did not significantly reduce CT utilization or improve diagnostic yield but was limited by low rates of participation and high baseline rates of selective imaging. Demonstrating value to clinicians through interventions that improve workflow is likely necessary to meaningfully change imaging practices.
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Affiliation(s)
- James E Andruchow
- Department of Emergency Medicine, University of Calgary Cumming School of Medicine, Foothills Medical Centre Room C-231, 1403-29st NW, Calgary, AB, T2N 2T9, Canada. .,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
| | | | - Andrew D McRae
- Department of Emergency Medicine, University of Calgary Cumming School of Medicine, Foothills Medical Centre Room C-231, 1403-29st NW, Calgary, AB, T2N 2T9, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Grant Innes
- Department of Emergency Medicine, University of Calgary Cumming School of Medicine, Foothills Medical Centre Room C-231, 1403-29st NW, Calgary, AB, T2N 2T9, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Shabnam Vatanpour
- Department of Emergency Medicine, University of Calgary Cumming School of Medicine, Foothills Medical Centre Room C-231, 1403-29st NW, Calgary, AB, T2N 2T9, Canada
| | - Dongmei Wang
- Department of Emergency Medicine, University of Calgary Cumming School of Medicine, Foothills Medical Centre Room C-231, 1403-29st NW, Calgary, AB, T2N 2T9, Canada
| | - Monica Taljaard
- Ottawa Hospital Research Institute, Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Eddy Lang
- Department of Emergency Medicine, University of Calgary Cumming School of Medicine, Foothills Medical Centre Room C-231, 1403-29st NW, Calgary, AB, T2N 2T9, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
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Clements W, McMahon GA, Joseph T, Goh GS, Kuang RJ, Smit DV, Varma D. Risk stratification of emergency department patients with acute pulmonary thromboembolism: Is chest pain a reason to investigate? J Med Imaging Radiat Oncol 2021; 65:864-868. [PMID: 34132053 DOI: 10.1111/1754-9485.13262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 05/25/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND This study aimed to risk-stratify chest pain as a presenting symptom in patients with a diagnosis of pulmonary thromboembolism (PE) to assess for any association. In addition, this study aimed to assess traditionally acknowledged PE risk factors in an Australian population. METHODS This was a retrospective single-centre cohort study assessing patients who presented to our emergency department during the period of 1 January 2019 to 1 January 2020. 730 consecutive patients who went on to computed tomography pulmonary angiography (CTPA) examination after presentation were included. RESULTS The rate of CTPA being positive in this study was 11.6% (85/730). Chest pain was associated with a non-significant reduction in the odds of PE (OR 0.774, P = 0.327). Univariate analysis showed significantly increased odds of a diagnosis of PE with presentation for leg pain/swelling (OR 6.670, P < 0.001). Multivariate analysis showed increasing age (OR 1.018, 95% CI 1.002-1.034, P = 0.024), clinical signs of a DVT (OR 3.194, 95% CI 1.803-5.657, P < 0.001) and positive D-dimer (OR 1.762, 95% CI 1.011-3.071, P = 0.046) were associated with increased odds of PE. CONCLUSION In this study, Emergency Department presentation with chest pain, whilst the most common reason to perform a CTPA, resulted in reduced odds with regard to the diagnosis of pulmonary thromboembolism. The use of CTPA in this setting may be rationalised according to other factors such as localised leg pain as a symptom, signs of DVT, increasing age or positive D-dimer.
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Affiliation(s)
- Warren Clements
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Monash University, Melbourne, Victoria, Australia.,National Trauma Research Institute, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - George Al McMahon
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Tim Joseph
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Gerard S Goh
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Monash University, Melbourne, Victoria, Australia.,National Trauma Research Institute, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Ronny Jd Kuang
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - De Villiers Smit
- National Trauma Research Institute, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Department of Emergency Medicine, Alfred Hospital, Melbourne, Victoria, Australia
| | - Dinesh Varma
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Monash University, Melbourne, Victoria, Australia.,National Trauma Research Institute, Central Clinical School, Monash University, Melbourne, Victoria, Australia
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30
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Sharma M, Burns AT, Yap K, Prior DL. The role of imaging in pulmonary hypertension. Cardiovasc Diagn Ther 2021; 11:859-880. [PMID: 34295710 DOI: 10.21037/cdt-20-295] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 07/17/2020] [Indexed: 01/10/2023]
Abstract
Pulmonary hypertension (PH) is a debilitating and potentially life threatening condition in which increased pressure in the pulmonary arteries may result from a variety of pathological processes. These can include disease primarily involving the pulmonary vasculature, but more commonly PH may result from left-sided heart disease, including valvular heart disease. Chronic thromboembolic pulmonary hypertension (CTEPH) is an important disease to identify because it may be amenable to surgical pulmonary artery endarterectomy or balloon pulmonary angioplasty. Parenchymal lung diseases are also widespread in the community. Any of these disease processes may result in adverse remodeling of the right ventricle and progressive right heart (RH) failure as a common final pathway. Because of the breadth of pathological processes which cause PH, multiple imaging modalities play vital roles in ensuring accurate diagnosis and classification, which will lead to application of the most appropriate therapy. Multimodality imaging may also provide important prognostic information and has a role in the assessment of response to therapies which ultimately dictate clinical outcomes. This review provides an overview of the wide variety of established imaging techniques currently in use, but also examines many of the novel imaging techniques which may be increasingly utilized in the future to guide comprehensive care of patients with PH.
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Affiliation(s)
- Meenal Sharma
- Department of Cardiology, St Vincent's Hospital Melbourne, Fitzroy, Australia
| | - Andrew T Burns
- Department of Cardiology, St Vincent's Hospital Melbourne, Fitzroy, Australia
| | - Kelvin Yap
- Department of Cardiology, St Vincent's Hospital Melbourne, Fitzroy, Australia
| | - David L Prior
- Department of Cardiology, St Vincent's Hospital Melbourne, Fitzroy, Australia.,Department of Medicine, The University of Melbourne at St Vincent's Hospital (Melbourne), Melbourne, Australia
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31
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Systematic review and meta-analysis of test accuracy for the diagnosis of suspected pulmonary embolism. Blood Adv 2021; 4:4296-4311. [PMID: 32915980 DOI: 10.1182/bloodadvances.2019001052] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 07/02/2020] [Indexed: 11/20/2022] Open
Abstract
Pulmonary embolism (PE) is a common, potentially life-threatening yet treatable condition. Prompt diagnosis and expeditious therapeutic intervention is of paramount importance for optimal patient management. Our objective was to systematically review the accuracy of D-dimer assay, compression ultrasonography (CUS), computed tomography pulmonary angiography (CTPA), and ventilation-perfusion (V/Q) scanning for the diagnosis of suspected first and recurrent PE. We searched Cochrane Central, MEDLINE, and EMBASE for eligible studies, reference lists of relevant reviews, registered trials, and relevant conference proceedings. 2 investigators screened and abstracted data. Risk of bias was assessed using Quality Assessment of Diagnostic Accuracy Studies-2 and certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation framework. We pooled estimates of sensitivity and specificity. The review included 61 studies. The pooled estimates for D-dimer sensitivity and specificity were 0.97 (95% confidence interval [CI], 0.96-0.98) and 0.41 (95% CI, 0.36-0.46) respectively, whereas CTPA sensitivity and specificity were 0.94 (95% CI, 0.89-0.97) and 0.98 (95% CI, 0.97-0.99), respectively, and CUS sensitivity and specificity were 0.49 (95% CI, 0.31-0.66) and 0.96 (95% CI, 0.95-0.98), respectively. Three variations of pooled estimates for sensitivity and specificity of V/Q scan were carried out, based on interpretation of test results. D-dimer had the highest sensitivity when compared with imaging. CTPA and V/Q scans (high probability scan as a positive and low/non-diagnostic/normal scan as negative) both had the highest specificity. This systematic review was registered on PROSPERO as CRD42018084669.
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32
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Patel L, Gandhi D, Westergard E, Ornes M, Lillyblad M, Skeik N. COVID-19 and venous thromboembolism: Known and unknown for imaging decisions. World J Radiol 2021; 13:64-74. [PMID: 33815684 PMCID: PMC8006055 DOI: 10.4329/wjr.v13.i3.64] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 03/02/2021] [Accepted: 03/22/2021] [Indexed: 02/06/2023] Open
Abstract
As we continue to fight against the current coronavirus disease-2019 (COVID-19) pandemic, healthcare professionals across the globe are trying to answer questions surrounding how to best help patients with the up-to-date available science while awaiting the development of new therapies and mass vaccination. Since early in the pandemic, studies indicated a heightened risk of venous thromboembolism (VTE) in COVID-19 infected patients. There have been differing expert opinions about how to assess pretest probability of VTE in this patient population. This has been partly due to the high prevalence of respiratory failure in this patient population and the use of D-dimer as a prognostic test which is also frequently elevated in patients with COVID-19 in absence of VTE. Some experts have argued for an approach similar to usual care with testing if clinical suspicion is high enough. Some have argued for more routine screening at different points of care. Others have even suggested empiric therapeutic anti-coagulation in moderate to severely ill COVID-19 patients. In the following article, we review and summarize the most current literature in hopes of assisting clinicians in decision making and guidance for when to be concerned for VTE in COVID-19 patients. We also discuss research gaps and share pathways currently being used within our institution.
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Affiliation(s)
- Love Patel
- Division of Hospital Medicine, Abbott Northwestern Hospital, Allina Health, Minneapolis, MN 55407, United States
| | - Darshan Gandhi
- Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, United States
| | - Emily Westergard
- Department of Graduate Medical Education, Abbott Northwestern Hospital, Minneapolis, MN 55408, United States
| | - Michael Ornes
- Division of Hospital Medicine, Abbott Northwestern Hospital, Allina Health, Minneapolis, MN 55407, United States
| | - Matthew Lillyblad
- Department of Pharmacy, Abbott Northwestern Hospital, Allina Health, Minneapolis, MN 55407, United States
| | - Nedaa Skeik
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Allina Health, Minneapolis, MN 55407, United States
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33
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Abumossalam AM, El Mekkawy MMN, Eid REA, Salah M, Ehab A. Echopulmonography as a Surrogate Modality in Disclosure of Occult Pulmonary Consequences of Pulmonary Vascular Occlusion. CURRENT RESPIRATORY MEDICINE REVIEWS 2021. [DOI: 10.2174/1573398x17666210129123946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background:
Diagnostic modalities of pulmonary embolism (PE) are still emerging day
after day with new tools and promising characteristic features.
Objective:
The aim of our work was to assess the diagnostic yield of echopulmonography in patients
with PE regarding pleural, parenchymal and vascular features of acute events and consequences.
Methods:
This is a prospective quasi-experimental study in which transthoracic echopulmonography
was adopted as a screening method for patients with clinical suspicion of PE in comparison to
Multi-Detector Computed Tomography Angiography of the chest, which is the best standard. This
study was conducted on 32 patients at the chest department in Mansoura University Hospital and a
Specialized Internal Medicine Hospital.
Results:
Echopulmonography was positive for pulmonary embolism at 68.75% but was of negative
value in 31.25%. On the other hand, CTPA was positive for pulmonary embolism in (71.78%) but
was of negative value in 28.12%. EPG confirm PE in 87% of patients diagnosed with PE by CTPA
with a false-negative result of 13%. EPG could exclude PE in 77.7% of patients who were negative
for PE by CTPA with a false-positive result of 22.2%.
Conclusion:
Echopulmonography might show promising features to be a substitute for computed
tomography angiography in the diagnosis of pulmonary embolism.
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Affiliation(s)
| | | | | | - Mohamed Salah
- Cardiology Medicine Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Ahmed Ehab
- Chest Medicine Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
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34
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Lei M, Liu C, Luo Z, Xu Z, Jiang Y, Lin J, Wang C, Jiang D. Diagnostic management of inpatients with a positive D-dimer test: developing a new clinical decision-making rule for pulmonary embolism. Pulm Circ 2021; 11:2045894020943378. [PMID: 33456753 PMCID: PMC7797584 DOI: 10.1177/2045894020943378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 06/26/2020] [Indexed: 11/16/2022] Open
Abstract
Background A positive D-dimer test has high sensitivity but relatively poor specificity
for the diagnosis of pulmonary embolism, causing difficulty for clinicians
unskilled in pulmonary embolism diagnosis in determining whether a patient
with a positive D-dimer test needs to undergo computed tomographic pulmonary
angiography. Objectives We sought to develop a new clinical decision-making rule based on a positive
D-dimer result to predict the probability of pulmonary embolism and to guide
clinicians in making decisions regarding the need for computed tomographic
pulmonary angiography. Methods We conducted a prospective, multicenter study in three hospitals in China. A
total of 3014 inpatients with positive D-dimer results were included. In the
derivation group, we built a multivariate logistic regression model and
deduced a regression equation from which our score was derived. Finally, we
validated the score in an independent cohort. Results Our score included nine variables (points): chest pain (1.4), chest tightness
(2.3), shortness of breath (3.6), hemoptysis (3.4), heart rate ≥100
beats/min (3.6), blood gas analysis (2.9), electrocardiogram presenting a
typical S1Q3T3 pattern (4.1), electrocardiogram findings (2.4), and
ultrasonic cardiogram findings (3.7). The sensitivities and specificities
were 100% and 86.94%, respectively, in the derivation group and 100% and
90.82%, respectively, in the validation group. Additionally, the observed
and predicted proportions of patients who underwent computed tomographic
pulmonary angiography were 16.82% and 10.76%, respectively, in the
derivation group and 18.72% and 11.40%, respectively, in the validation
group. Conclusions The new score can categorize inpatients with a positive D-dimer test as
pulmonary embolism-likely or pulmonary embolism-unlikely, thus reducing
unnecessary computed tomographic pulmonary angiography examinations.
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Affiliation(s)
- Min Lei
- Department of Geriatric Medicine, The Fuling Central Hospital of Chongqing, Chongqing, China
| | - Chang Liu
- Department of Respiratory medicine, The Second Clinical Hospital of Chongqing Medical University, Chongqing, China
| | - Zhuang Luo
- Department of Respiratory Medicine, The First Clinical Hospital of Kunming Medical College, Kunming, China
| | - Zhibo Xu
- Department of Respiratory Medicine, The Second People's Hospital of Chengdu City, Chengdu, China
| | - Youfan Jiang
- Department of Respiratory medicine, The Second Clinical Hospital of Chongqing Medical University, Chongqing, China
| | - Jiachen Lin
- Department of Respiratory Medicine, The Second People's Hospital of Chengdu City, Chengdu, China
| | - Chu Wang
- Department of Respiratory Medicine, The First Clinical Hospital of Kunming Medical College, Kunming, China
| | - Depeng Jiang
- Department of Respiratory medicine, The Second Clinical Hospital of Chongqing Medical University, Chongqing, China
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35
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Wang RC, Miglioretti DL, Marlow EC, Kwan ML, Theis MK, Bowles EJA, Greenlee RT, Rahm AK, Stout NK, Weinmann S, Smith-Bindman R. Trends in Imaging for Suspected Pulmonary Embolism Across US Health Care Systems, 2004 to 2016. JAMA Netw Open 2020; 3:e2026930. [PMID: 33216141 PMCID: PMC7679949 DOI: 10.1001/jamanetworkopen.2020.26930] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE In response to calls to reduce unnecessary diagnostic testing with computed tomographic pulmonary angiography (CTPA) for suspected pulmonary embolism (PE), there have been growing efforts to create and implement decision rules for PE testing. It is unclear if the use of advanced imaging tests for PE has diminished over time. OBJECTIVE To assess the use of advanced imaging tests, including chest computed tomography (CT) (ie, all chest CT except for CTPA), CTPA, and ventilation-perfusion (V/Q) scan, for PE from 2004 to 2016. DESIGN, SETTING, AND PARTICIPANTS Cohort study of adults by age group (18-64 years and ≥65 years) enrolled in 7 US integrated and mixed-model health care systems. Joinpoint regression analysis was used to identify years with statistically significant changes in imaging rates and to calculate average annual percentage change (growth) from 2004 to 2007, 2008 to 2011, and 2012 to 2016. Analyses were conducted between June 11, 2019, and March 18, 2020. MAIN OUTCOMES AND MEASURES Rates of chest CT, CTPA, and V/Q scan by year and age, as well as annual change in rates over time. RESULTS Overall, 3.6 to 4.8 million enrollees were included each year of the study, for a total of 52 343 517 person-years of follow-up data. Adults aged 18 to 64 years accounted for 42 223 712 person-years (80.7%) and those 65 years or older accounted for 10 119 805 person-years (19.3%). Female enrollees accounted for 27 712 571 person-years (52.9%). From 2004 and 2016, chest CT use increased by 66.3% (average annual growth, 4.4% per year), CTPA use increased by 450.0% (average annual growth, 16.3% per year), and V/Q scan use decreased by 47.1% (decreasing by 4.9% per year). The use of CTPA increased most rapidly from 2004 to 2006 (44.6% in those aged 18-64 years and 43.9% in those ≥65 years), with ongoing rapid growth from 2006 to 2010 (annual growth, 19.8% in those aged 18-64 years and 18.3% in those ≥65 years) and persistent but slower growth in the most recent years (annual growth, 4.3% in those aged 18-64 years and 3.0% in those ≥65 years from 2010 to 2016). The use of V/Q scanning decreased steadily since 2004. CONCLUSIONS AND RELEVANCE From 2004 to 2016, rates of chest CT and CTPA for suspected PE continued to increase among adults but at a slower pace in more contemporary years. Efforts to combat overuse have not been completely successful as reflected by ongoing growth, rather than decline, of chest CT use. Whether the observed imaging use was appropriate or was associated with improved patient outcomes is unknown.
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Affiliation(s)
- Ralph C. Wang
- Department of Emergency Medicine, University of California, San Francisco
| | - Diana L. Miglioretti
- Department of Public Health Sciences, University of California, Davis
- Comprehensive Cancer Center, University of California, Davis
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle
| | - Emily C. Marlow
- Department of Public Health Sciences, University of California, Davis
| | - Marilyn L. Kwan
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - May K. Theis
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle
| | - Erin J. A. Bowles
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle
| | - Robert T. Greenlee
- Marshfield Clinic Research Institute, Marshfield Clinic Health System, Marshfield, Wisconsin
| | - Alanna K. Rahm
- Genomic Medicine Institute, Geisinger, Danville, Pennsylvania
| | - Natasha K. Stout
- Massachusetts Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston
| | - Sheila Weinmann
- now with Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
- Center for Integrated Health Research, Kaiser Permanente Hawaii, Honolulu
| | - Rebecca Smith-Bindman
- Department of Radiology and Biomedical Imaging, University of California, San Francisco
- Department of Epidemiology and Biostatistics, University of California, San Francisco
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
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36
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Buk M, Rengier F, Mokry T, Riffel J, Giannitsis E, Kihm L, Malikova H, Kauczor HU, von Stackelberg O, Weber TF. Appropriateness of CT pulmonary angiograms according to current diagnostic guidelines based on risk stratification: A retrospective single-center study. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2020; 165:51-56. [PMID: 33087940 DOI: 10.5507/bp.2020.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 10/07/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND AND AIM Assessment of appropriateness of CT pulmonary angiograms (CTPA) in patients with suspected pulmonary embolism (PE) is based on risk stratification algorithms such as simplified the Geneva Score (sGS) in combination with D-dimer blood tests. The aim of this study was to validate the diagnostic yield and appropriateness of CTPA examinations in accordance with 2014 European Society of Cardiology (ESC) guidelines. MATERIALS AND METHODS Data from 155 outpatients who underwent CTPA for clinical suspicion of PE were gathered from the radiology information system (RIS) and the clinical information system (CIS). We assessed the presence of sGS items and D-dimer blood test results in RIS from CTPA request forms and from clinical documentation in CIS. RESULTS Based on the RIS, there were 2.6% patients with high (sGS≥3) and 97.4% patients with low pre-test PE probability (sGS<3), and CTPA indication was formally comprehendible in 75.5% using sGS and D-dimer blood tests. Based on RIS and CIS data in combination, there were 41.3% patients with high and 58.7% patients with low pre-test PE probability, and CTPA indication was formally comprehendible in 88.4%. Using RIS and CIS in combination, PE probability was upgraded from low to high probability in 39.7% compared with RIS alone. In 12.9%, there was a lack of data in RIS for CTPA justification. CONCLUSION There is a high diagnostic yield when applying current diagnostic guidelines to our data. There was however a notable discrepancy between the data transferred to the CTPA request forms from the full clinical documentation, therefore not readily available for clinical decision making.
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Affiliation(s)
- Michal Buk
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Germany.,Department of Radiology, Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic.,Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Fabian Rengier
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), University of Heidelberg, Heidelberg, Germany
| | - Theresa Mokry
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Germany
| | - Johannes Riffel
- Department of Cardiology, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Lars Kihm
- Department of Endocrinology, University Hospital Heidelberg, Heidelberg, Germany
| | - Hana Malikova
- Department of Radiology, Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic.,Institute of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Hans-Ulrich Kauczor
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), University of Heidelberg, Heidelberg, Germany
| | | | - Tim Frederik Weber
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Germany
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Maritano Furcada J, Castro HM, De Vito EL, Grande Ratti MF, Posadas-Martínez ML, Giunta DH, Vazquez FJ, Ferreyro BL. Diagnosis of pulmonary embolism in patients with acute exacerbations of chronic obstructive pulmonary disease: A cross-sectional study. CLINICAL RESPIRATORY JOURNAL 2020; 14:1176-1181. [PMID: 32780471 DOI: 10.1111/crj.13257] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 08/01/2020] [Accepted: 08/06/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Pulmonary embolism (PE) remains a frequent complication in patients with chronic obstructive pulmonary disease (COPD). It is unclear that the extent to which the traditional risk stratifying scores for PE are accurate in this population. METHODS Cross-sectional study of adult patients with COPD and suspected PE included in an Institutional Registry of Thromboembolic Disease at a tertiary teaching hospital in the city of Buenos Aires, Argentina. We estimated the area under the receiver operating characteristic curves (AU-ROC), sensitivity and specificity of the Wells and Geneva scores using a positive computed tomography angiography as the gold standard for PE. We also estimated the sensitivity and specificity for the presence of isolated worsening of dyspnea at presentation, without other cardinal symptoms of acute exacerbation of COPD. RESULTS A total of 168 patients were included, of which 22% had confirmed PE. The AUC was 0.66 (95% CI 0.56-0.76) and 0.56 (95% CI 0.45-0.67) for the Wells and Geneva, respectively. Considering the most widely used cutoff points, the sensitivity and specificity were 24% and 90% for the Wells and 59% and 43% for the Geneva score, respectively. Isolated worsening of dyspnea on presentation had a sensitivity of 92% and specificity of 37%. CONCLUSIONS Both Wells and Geneva scores exhibit poor diagnostic accuracy for the diagnosis of PE in patients with COPD. The presence of isolated worsening of dyspnea on presentation could be an easy to identify criteria for the initial triage in this population. Further validation of our findings remains warranted.
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Affiliation(s)
| | | | - Eduardo Luis De Vito
- Institute of Medical Research Alfredo Lanari, Universidad de Buenos Aires, Buenos Aires, Argentina
| | | | | | - Diego Hernán Giunta
- Internal Medicine Research Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | - Bruno Leonel Ferreyro
- Internal Medicine Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.,Sinai Health System/University Health Network and Interdepartmental Division of Critical Care Medicine, University of Toronto, ON, Canada.,Institute for Health Policy, Management, and Evaluation, University of Toronto, ON, Canada
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38
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Sin D, McLennan G, Rengier F, Haddadin I, Heresi GA, Bartholomew JR, Fink MA, Thompson D, Partovi S. Acute pulmonary embolism multimodality imaging prior to endovascular therapy. Int J Cardiovasc Imaging 2020; 37:343-358. [PMID: 32862293 PMCID: PMC7456521 DOI: 10.1007/s10554-020-01980-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 08/19/2020] [Indexed: 12/15/2022]
Abstract
The manuscript discusses the application of CT pulmonary angiography, ventilation–perfusion scan, and magnetic resonance angiography to detect acute pulmonary embolism and to plan endovascular therapy. CT pulmonary angiography offers high accuracy, speed of acquisition, and widespread availability when applied to acute pulmonary embolism detection. This imaging modality also aids the planning of endovascular therapy by visualizing the number and distribution of emboli, determining ideal intra-procedural catheter position for treatment, and signs of right heart strain. Ventilation–perfusion scan and magnetic resonance angiography with and without contrast enhancement can also aid in the detection and pre-procedural planning of endovascular therapy in patients who are not candidates for CT pulmonary angiography.
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Affiliation(s)
- David Sin
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - Gordon McLennan
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - Fabian Rengier
- Section of Emergency Radiology, Clinic for Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Ihab Haddadin
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - Gustavo A Heresi
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - John R Bartholomew
- Section of Vascular Medicine, Heart and Vascular Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - Matthias A Fink
- Section of Emergency Radiology, Clinic for Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Dustin Thompson
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - Sasan Partovi
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA.
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39
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Abstract
Pulmonary embolism is a common and potentially fatal cardiovascular disorder that must be promptly diagnosed and treated. The diagnosis, risk assessment, and management of pulmonary embolism have evolved with a better understanding of efficient use of diagnostic and therapeutic options. The use of either clinical probability adjusted or age adjusted D-dimer interpretation has led to a reduction in diagnostic imaging to exclude pulmonary embolism. Direct oral anticoagulation therapies are safe, effective, and convenient treatments for most patients with acute venous thromboembolism, with a lower risk of bleeding than vitamin K antagonists. These oral therapeutic options have opened up opportunities for safe outpatient management of pulmonary embolism in selected patients. Recent clinical trials exploring the use of systemic thrombolysis in intermediate to high risk pulmonary embolism suggest that this therapy should be reserved for patients with evidence of hemodynamic compromise. The role of low dose systemic or catheter directed thrombolysis in other patient subgroups is uncertain. After a diagnosis of pulmonary embolism, all patients should be assessed for risk of recurrent venous thromboembolism to guide duration of anticoagulation. Patients with a venous thromboembolism associated with a strong, transient, provoking risk factor can safely discontinue anticoagulation after three months of treatment. Patients with an ongoing strong risk factor, such as cancer, or unprovoked events are at increased risk of recurrent events and should be considered for extended treatment. The use of a risk prediction score can help to identify patients with unprovoked venous thromboembolism who can benefit from extended duration therapy. Despite major advances in the management of pulmonary embolism, up to half of patients report chronic functional limitations. Such patients should be screened for chronic thromboembolic pulmonary hypertension, but only a small proportion will have this as the explanation of their symptoms. In the remaining patients, future studies are needed to understand the pathophysiology and explore interventions to improve quality of life.
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Affiliation(s)
- Lisa Duffett
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Lana A Castellucci
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Melissa A Forgie
- Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
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40
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Patel H, Sun H, Hussain AN, Vakde T. Advances in the Diagnosis of Venous Thromboembolism: A Literature Review. Diagnostics (Basel) 2020; 10:E365. [PMID: 32498355 PMCID: PMC7345080 DOI: 10.3390/diagnostics10060365] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 05/28/2020] [Accepted: 05/30/2020] [Indexed: 12/14/2022] Open
Abstract
The incidence of venous thromboembolism (VTE), including lower extremity deep vein thrombosis (DVT) and pulmonary embolism (PE) is increasing. The increase in suspicion for VTE has lowered the threshold for performing imaging studies to confirm diagnosis of VTE. However, only 20% of suspected cases have a confirmed diagnosis of VTE. Development of pulmonary embolism rule-out criteria (PERC) and update in pre-test probability have changed the paradigm of ruling-out patient with low index of suspicion. The D-dimer test in conjunction to the pre-test probability has been utilized in VTE diagnosis. The age appropriate D-dimer cutoff and inclusion of YEARS algorithm (signs of the DVT, hemoptysis and whether PE is the likely diagnosis) for the D-dimer cutoff have been recent updates in the evaluation of suspected PE. Multi-detector computed tomography pulmonary angiography (CTPA) and compression ultrasound (CUS) are the preferred imaging modality to diagnose PE and DVT respectively. The VTE diagnostic algorithm do differ in pregnant individuals. The prerequisite of avoiding excessive radiation has recruited planar ventilation-perfusion (V/Q) scan as preferred in pregnant patients to evaluate for PE. The modification of CUS protocol with addition of the Valsalva maneuver should be performed while evaluating DVT in pregnant individual.
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Affiliation(s)
- Harish Patel
- Department of Medicine, BronxCare Hospital Center a Clinical Affiliate of Mt Sinai Health Systems and Academic affiliate of Icahn School of Medicine, Bronx, NY 10457, USA; (H.S.); (A.N.H.); (T.V.)
| | - Haozhe Sun
- Department of Medicine, BronxCare Hospital Center a Clinical Affiliate of Mt Sinai Health Systems and Academic affiliate of Icahn School of Medicine, Bronx, NY 10457, USA; (H.S.); (A.N.H.); (T.V.)
| | - Ali N. Hussain
- Department of Medicine, BronxCare Hospital Center a Clinical Affiliate of Mt Sinai Health Systems and Academic affiliate of Icahn School of Medicine, Bronx, NY 10457, USA; (H.S.); (A.N.H.); (T.V.)
| | - Trupti Vakde
- Department of Medicine, BronxCare Hospital Center a Clinical Affiliate of Mt Sinai Health Systems and Academic affiliate of Icahn School of Medicine, Bronx, NY 10457, USA; (H.S.); (A.N.H.); (T.V.)
- Division of the Pulmonary and Critical Care, BronxCare Hospital Center a Clinical Affiliate of Mt Sinai Health Systems and Academic Affiliate of Icahn School of Medicine, Bronx, NY 10457, USA
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41
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Jannati M, Ardecani AA. Prevention of Pulmonary and Venous Thromboembolism Post Coronary Artery Bypass Graft Surgery - Literature Review. Braz J Cardiovasc Surg 2020; 35:368-374. [PMID: 32549108 PMCID: PMC7299585 DOI: 10.21470/1678-9741-2018-0345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objective The current review evaluates recent literature on the different aspects of prophylaxis in postoperative pulmonary and venous thromboembolism and their main risk factors. Methods The literature survey was carried out based on the PubMed data using the keywords “coronary artery bypass graft” and “venous thromboembolism” as components of the search field title. Results Studies reported several risk factors for postoperative thromboembolism including advanced age, postoperative immobilization, type of thromboprophylaxis, obesity, and location of the surgery. Conclusion According to the studies, tailored prophylaxis could be easily adapted to decrease the intensity and duration of postoperative thromboembolism in a patient with several disorders and comorbidities, especially in cardiovascular disease.
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Affiliation(s)
- Mansour Jannati
- Shiraz University of Medical Sciences Faghihi Hospital Department of Cardiovascular Surgery Shiraz Iran Department of Cardiovascular Surgery, Faghihi Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Alireza Abdi Ardecani
- Shiraz University of Medical Sciences Faghihi Hospital Department of Cardiovascular Surgery Shiraz Iran Department of Cardiovascular Surgery, Faghihi Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
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Barais M, Fossard E, Dany A, Montier T, Stolper E, Van Royen P. Accuracy of the general practitioner's sense of alarm when confronted with dyspnoea and/or chest pain: a prospective observational study. BMJ Open 2020; 10:e034348. [PMID: 32075841 PMCID: PMC7044836 DOI: 10.1136/bmjopen-2019-034348] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVES Dyspnoea and chest pain are symptoms shared with multiple pathologies ranging from the benign to life-threatening diseases. A Gut Feelings Questionnaire (GFQ) has been validated to measure the general practitioner's (GPs) sense of alarm or sense of reassurance. The aim of the study was to estimate the diagnostic test accuracy of GPs' sense of alarm when confronted with dyspnoea and chest pain. DESIGN AND SETTINGS Prospective observational study in general practice. PARTICIPANTS Patients aged between 18 and 80 years, consulting their GP for dyspnoea and/or chest pain, were considered for enrolment. These GPs had to complete the GFQ immediately after the consultation. PRIMARY OUTCOME MEASURES Life-threatening and non-life-threatening diseases have previously been defined according to the pathologies or symptoms in the International Classification of Primary Care (ICPC)-2 classification. The index test was the sense of alarm and the reference standard was the final diagnosis at 4 weeks. RESULTS 25 GPs filled in 235 GFQ questionnaires. The positive likelihood ratio for the sense of alarm was 2.12 (95% CI 1.49 to 2.82), the negative likelihood ratio was 0.55 (95% CI 0.37 to 0.77). CONCLUSIONS Where the physician experienced a sense of alarm when a patient consulted him/her for dyspnoea and/or chest pain, the post-test odds that this patient had, in fact, a life-threatening disease was about twice as high as the pretest odds. TRIAL REGISTRATION NUMBER NCT02932982.
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Affiliation(s)
- Marie Barais
- Department of General Practice, EA 7479 SPURBO, Faculté de Médecine et des Sciences de la Santé, Université de Bretagne Occidentale, Brest, Bretagne, France
| | - Emilie Fossard
- Department of General Practice, EA 7479 SPURBO, Faculté de Médecine et des Sciences de la Santé, Université de Bretagne Occidentale, Brest, Bretagne, France
| | - Antoine Dany
- Department of Public Health, EA 7479 SPURBO, Faculté de Médecine et des Sciences de la Santé, Université de Bretagne Occidentale, Brest, Bretagne, France
| | - Tristan Montier
- Inserm UMR1078, Faculté de Médecine et des Sciences de la Santé, Université de Bretagne Occidentale, Brest, Bretagne, France
| | - Erik Stolper
- CAPHRI School for Public Health and Primary Care, University of Maastricht, Maastricht, The Netherlands
- Department of Primary and Interdisciplinary Care, University of Antwerp Faculty of Medicine and Health Sciences, Wilrijk, Antwerp, Belgium
| | - Paul Van Royen
- Department of Primary and Interdisciplinary Care, University of Antwerp Faculty of Medicine and Health Sciences, Wilrijk, Antwerp, Belgium
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43
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Esiéné A, Tochie JN, Metogo JAM, Etoundi PO, Minkande JZ. A comparative analysis of the diagnostic performances of four clinical probability models for acute pulmonary embolism in a sub-Saharan African population: a cross-sectional study. BMC Pulm Med 2019; 19:263. [PMID: 31881882 PMCID: PMC6935247 DOI: 10.1186/s12890-019-1037-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 12/19/2019] [Indexed: 11/24/2022] Open
Abstract
Background The diagnosis of acute pulmonary embolism (PE) is one of the most challenging in emergency settings where prompt and accurate decisions need to be taken for life-saving purposes. Here, the assessment of the clinical probability of PE is a paramount step in its diagnosis. Although clinical probability models (CPM) for PE are routinely used in emergency departments (EDs) of low-resource settings, few studies have cited their diagnostic performances in sub-Saharan Africa (SSA). We aimed to comparatively assess the accuracy of four CPM in the diagnosis of acute PE in sub-Saharan Africans. Methods We carried out a cross-sectional study to compare the sensitivity, specificity, positive and negative predictive values and accuracy of four CPM namely; the Wells, simplified Wells, revised Geneva and the simplified revised Geneva (SRG) Scores to computed tomography pulmonary angiography (CTPA) in all adults patients with suspected PE admitted to the EDs of the Gynaeco-obstetric and Paediatric Hospital of Yaoundé and the Yaoundé Central Hospital in Cameroon between January 1, 2017 and April 30, 2018. Results In total, we enrolled 30 patients with clinical suspicion of acute PE. PE was confirmed on CTPA in 16 (53.3%) cases. Their mean age was 53.7 ± 15.5 years and 36.7% were males. All four scores had a diagnostic performance superior to 50% in all criteria assessed. The simplified Wells score had the highest sensitivity (62.5%) followed by the Wells score (56.3%). The SRG score had the highest specificity (71.4%). The score with highest PPV was the SRG score (66.7%) and that with the highest NPV was the Wells score (56.3%). Overall the models with the highest accuracies were the Wells and SRG scores (60% for each). Conclusion All CPM had a suboptimal diagnostic performance, perhaps highlighting the need of a more optimal CPM for acute PE in SSA. However, the Wells and the SRG scores appeared to be most accurate than the other two scores in the ED. Hence, both or either of them may be used in first intention to predict PE and guide which ED patients should undergo further investigations in an emergency SSA setting.
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Affiliation(s)
- Agnès Esiéné
- Department of Anesthesiology and Critical Care, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon.,Department of Emergency Medicine, Anesthesiology and Critical Care, Yaounde Central Hospital, Yaoundé, Cameroon
| | - Joel Noutakdie Tochie
- Department of Anesthesiology and Critical Care, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon.
| | - Junette Arlette Mbengono Metogo
- Department of Anesthesiology and Critical Care, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon.,Department of Emergency Medicine, Anesthesiology and Critical Care, Douala General Hospital, Douala, Cameroon
| | - Paul Owono Etoundi
- Department of Anesthesiology and Critical Care, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon.,Department of Emergency Medicine, Anesthesiology and Critical Care, Yaounde Central Hospital, Yaoundé, Cameroon
| | - Jacqueline Ze Minkande
- Department of Anesthesiology and Critical Care, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon.,Department of Emergency Medicine, Anesthesiology and Critical Care, Gynaeco-Obstetrics and Paediatric Hospital, Yaoundé, Cameroon
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44
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Bajc M, Schümichen C, Grüning T, Lindqvist A, Le Roux PY, Alatri A, Bauer RW, Dilic M, Neilly B, Verberne HJ, Delgado Bolton RC, Jonson B. EANM guideline for ventilation/perfusion single-photon emission computed tomography (SPECT) for diagnosis of pulmonary embolism and beyond. Eur J Nucl Med Mol Imaging 2019; 46:2429-2451. [PMID: 31410539 PMCID: PMC6813289 DOI: 10.1007/s00259-019-04450-0] [Citation(s) in RCA: 110] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 07/17/2019] [Indexed: 12/18/2022]
Abstract
These guidelines update the previous EANM 2009 guidelines on the diagnosis of pulmonary embolism (PE). Relevant new aspects are related to (a) quantification of PE and other ventilation/perfusion defects; (b) follow-up of patients with PE; (c) chronic PE; and (d) description of additional pulmonary physiological changes leading to diagnoses of left ventricular heart failure (HF), chronic obstructive pulmonary disease (COPD) and pneumonia. The diagnosis of PE should be reported when a mismatch of one segment or two subsegments is found. For ventilation, Technegas or krypton gas is preferred over diethylene triamine pentaacetic acid (DTPA) in patients with COPD. Tomographic imaging with V/PSPECT has higher sensitivity and specificity for PE compared with planar imaging. Absence of contraindications makes V/PSPECT an essential method for the diagnosis of PE. When V/PSPECT is combined with a low-dose CT, the specificity of the test can be further improved, especially in patients with other lung diseases. Pitfalls in V/PSPECT interpretation are discussed. In conclusion, V/PSPECT is strongly recommended as it accurately establishes the diagnosis of PE even in the presence of diseases like COPD, HF and pneumonia and has no contraindications.
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Affiliation(s)
- Marika Bajc
- Department of Clinical Sciences, Clinical Physiology and Nuclear Medicine, University of Lund, Lund, Sweden.
| | - Carl Schümichen
- University of Rostock, Formerly Clinic for Nuclear Medicine, Rostock, Germany
| | - Thomas Grüning
- Department of Nuclear Medicine, University Hospitals Plymouth, Plymouth, UK
| | - Ari Lindqvist
- Research Unit of Pulmonary Diseases, Clinical Research Institute, HUS Helsinki University Hospital, Helsinki, Finland
| | | | - Adriano Alatri
- Division of Angiology, Heart and Vessel Department, Lausanne University Hospital, Lausanne, Switzerland
| | - Ralf W Bauer
- RNS Gemeinschaftspraxis, Wiesbaden, Germany
- Department of Diagnostic and Interventional Radiology, Goethe University Frankfurt (Main), Frankfurt, Germany
| | - Mirza Dilic
- Clinic of Heart and Blood Vessel Disease, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Brian Neilly
- Department of Nuclear Medicine, Royal Infirmary, Glasgow, UK
| | - Hein J Verberne
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Roberto C Delgado Bolton
- Department of Diagnostic Imaging (Radiology) and Nuclear Medicine, University Hospital San Pedro and Centre for Biomedical Research of La Rioja (CIBIR), Logroño, La Rioja, Spain
| | - Bjorn Jonson
- Department of Clinical Sciences, Clinical Physiology and Nuclear Medicine, University of Lund, Lund, Sweden
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American Society of Hematology 2018 guidelines for management of venous thromboembolism: diagnosis of venous thromboembolism. Blood Adv 2019; 2:3226-3256. [PMID: 30482764 DOI: 10.1182/bloodadvances.2018024828] [Citation(s) in RCA: 224] [Impact Index Per Article: 44.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Accepted: 10/02/2018] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Modern diagnostic strategies for venous thromboembolism (VTE) incorporate pretest probability (PTP; prevalence) assessment. The ability of diagnostic tests to correctly identify or exclude VTE is influenced by VTE prevalence and test accuracy characteristics. OBJECTIVE These evidence-based guidelines are intended to support patients, clinicians, and health care professionals in VTE diagnosis. Diagnostic strategies were evaluated for pulmonary embolism (PE), deep vein thrombosis (DVT) of the lower and upper extremity, and recurrent VTE. METHODS The American Society of Hematology (ASH) formed a multidisciplinary panel including patient representatives. The McMaster University GRADE Centre completed systematic reviews up to 1 October 2017. The panel prioritized questions and outcomes and used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess evidence and make recommendations. Test accuracy estimates and VTE population prevalence were used to model expected outcomes in diagnostic pathways. Where modeling was not feasible, management and accuracy studies were used to formulate recommendations. RESULTS Ten recommendations are presented, by PTP for patients with suspected PE and lower extremity DVT, and for recurrent VTE and upper extremity DVT. CONCLUSIONS For patients at low (unlikely) VTE risk, using D-dimer as the initial test reduces the need for diagnostic imaging. For patients at high (likely) VTE risk, imaging is warranted. For PE diagnosis, ventilation-perfusion scanning and computed tomography pulmonary angiography are the most validated tests, whereas lower or upper extremity DVT diagnosis uses ultrasonography. Research is needed on new diagnostic modalities and to validate clinical decision rules for patients with suspected recurrent VTE.
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46
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Chien CH, Shih FC, Chen CY, Chen CH, Wu WL, Mak CW. Unenhanced multidetector computed tomography findings in acute central pulmonary embolism. BMC Med Imaging 2019; 19:65. [PMID: 31412797 PMCID: PMC6692926 DOI: 10.1186/s12880-019-0364-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 07/31/2019] [Indexed: 11/10/2022] Open
Abstract
Background Computed tomography pulmonary angiography (CTPA) is the gold standard for the diagnosis of pulmonary embolism (PE). However, contrast is contraindicated in some patients. The purpose of this study was to determine the diagnostic accuracy of unenhanced multidetector CT (MDCT) for diagnosis of central PE using CTPA as the gold standard. Methods The records of patients with suspected PE seen between 2010 and 2013 were retrospectively reviewed. Inclusion criteria were an acute, central PE confirmed by CTPA and non-enhanced MDCT before contrast injection. Patients with a PE ruled out by CTPA served as a control group. MDCT findings studied were high-attenuation emboli in pulmonary artery (PA), main PA dilatation > 33.2 mm, and peripheral wedge-shaped consolidation. Receiver operating characteristic (ROC) analysis was used to determine the sensitivity and specificity of unenhanced MDCT to detect PE. Wells score of all patients were calculated using data extracted from medical records prior to imaging analysis. Results Thirty-two patients with a PE confirmed by CTPA and 32 with a PE ruled out by CTPA were included. Among the three main MDCT findings, high-attenuation emboli in the PA showed best diagnostic performance (Sensitivity 72.9%; Specificity 100%), followed by main PA dilatation > 33.2 mm (sensitivity 46.9%; specificity 90.6%), and peripheral wedge-shaped consolidation (sensitivity 43.8%; specificity 78.1%). Given any one or more positive findings on unenhanced MDCT, the sensitivity was 96.9% and specificity was 71.9% for a diagnosis of PE in patients. The area under the curve (AUC) of a composite measure of unenhanced MDCT findings (0.909) was significantly higher than that of the Wells score (0.688), indicating unenhanced MDCT was reliable for detecting PE than Wells score. Conclusions Unenhanced MDCT is an alternative for the diagnosis of acute central PE when CTPA is not available.
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Affiliation(s)
- Chiao-Hsuan Chien
- Department of Radiology, Chi-Mei Medical Center, No.901, Zhonghua Rd., Yongkang Dist, Tainan City, 710, Taiwan, Republic of China. .,Graduate Institute of Medical Science, College of Health Science, Chang Jung Christian University, Tainan, Taiwan.
| | - Fu-Chieh Shih
- Department of Emergency, Chi-Mei Medical Center, No. 901, Zhonghua Rd., Yongkang Dist, Tainan City, 710, Taiwan, Republic of China
| | - Chin-Yu Chen
- Department of Radiology, Chi-Mei Medical Center, No.901, Zhonghua Rd., Yongkang Dist, Tainan City, 710, Taiwan, Republic of China
| | - Chia-Hui Chen
- Department of Radiology, Chi-Mei Medical Center, No.901, Zhonghua Rd., Yongkang Dist, Tainan City, 710, Taiwan, Republic of China
| | - Wan-Ling Wu
- Department of Radiology, Chi-Mei Medical Center, No.901, Zhonghua Rd., Yongkang Dist, Tainan City, 710, Taiwan, Republic of China
| | - Chee-Wai Mak
- Department of Radiology, Chi-Mei Medical Center, No.901, Zhonghua Rd., Yongkang Dist, Tainan City, 710, Taiwan, Republic of China
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Delluc A, Miranda S, Exter PD, Louzada M, Alatri A, Ahn S, Monreal M, Khorana A, Huisman MV, Wells PS, Carrier M. Accuracy of the Ottawa score in risk stratification of recurrent venous thromboembolism in patients with cancer-associated venous thromboembolism: a systematic review and meta-analysis. Haematologica 2019; 105:1436-1442. [PMID: 31273089 PMCID: PMC7193505 DOI: 10.3324/haematol.2019.222828] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 06/28/2019] [Indexed: 12/21/2022] Open
Abstract
In patients with cancer-associated venous thromboembolism, knowledge of the estimated rate of recurrent events is important for clinical decision-making regarding anticoagulant therapy. The Ottawa score is a clinical prediction rule designed for this purpose, stratifying patients according to their risk of recurrent venous thromboembolism during the first six months of anticoagulation. We conducted a systematic review and meta-analysis of studies validating either the Ottawa score in its original or modified versions. Two investigators independently reviewed the relevant articles published from 1st June 2012 to 15th December 2018 and indexed in MEDLINE and EMBASE. Nine eligible studies were identified; these included a total of 14,963 patients. The original score classified 49.3% of the patients as high-risk, with a sensitivity of 0.7 [95% confidence interval (CI): 0.6-0.8], a 6-month pooled rate of recurrent venous thromboembolism of 18.6% (95%CI: 13.9-23.9). In the low-risk group, the recurrence rate was 7.4% (95%CI: 3.4-12.5). The modified score classified 19.8% of the patients as low-risk, with a sensitivity of 0.9 (95%CI: 0.4-1.0) and a 6-month pooled rate of recurrent venous thromboembolism of 2.2% (95%CI: 1.6-2.9). In the high-risk group, recurrence rate was 10.2% (95%CI: 6.4-14.6). Limitations of our analysis included type and dosing of anticoagulant therapy. We conclude that new therapeutic strategies are needed in patients at high risk for recurrent cancer-associated venous thromboembolism. Low-risk patients, as per the modified score, could be good candidates for oral anticoagulation. (This systematic review was registered with the International Prospective Registry of Systematic Reviews as: PROSPERO CRD42018099506).
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Affiliation(s)
- Aurélien Delluc
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottowa, Ontario, Canada
| | - Sébastien Miranda
- Normandie University, UNIROUEN, INSERM U1096 and Rouen University Hospital, Department of Internal Medicine, Vascular and Thrombosis Unit, F 76000 Rouen, France
| | - Paul den Exter
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Martha Louzada
- Department of Medicine, Division of Hematology, University of Western Ontario, London, Ontario, Canada
| | - Adriano Alatri
- Division of Angiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Shin Ahn
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Manuel Monreal
- Department of Internal Medicine. Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Alok Khorana
- Cleveland Clinic-Taussig Cancer Center, Cleveland, OH, USA
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Philip S Wells
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottowa, Ontario, Canada
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottowa, Ontario, Canada
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Hur DJ, Sugeng L. Non-invasive Multimodality Cardiovascular Imaging of the Right Heart and Pulmonary Circulation in Pulmonary Hypertension. Front Cardiovasc Med 2019; 6:24. [PMID: 30931315 PMCID: PMC6427926 DOI: 10.3389/fcvm.2019.00024] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Accepted: 02/20/2019] [Indexed: 12/13/2022] Open
Abstract
Pulmonary hypertension (PH) is defined as resting mean pulmonary arterial pressure (mPAP) ≥25 millimeters of mercury (mmHg) via right heart (RH) catheterization (RHC), where increased afterload in the pulmonary arterial vasculature leads to alterations in RH structure and function. Mortality rates have remained high despite therapy, however non-invasive imaging holds the potential to expedite diagnosis and lead to earlier initiation of treatment, with the hope of improving prognosis. While historically the right ventricle (RV) had been considered a passive chamber with minimal role in the overall function of the heart, in recent years in the evaluation of PH and RH failure the anatomical and functional assessment of the RV has received increased attention regarding its performance and its relationship to other structures in the RH-pulmonary circulation. Today, the RV is the key determinant of patient survival. This review provides an overview and summary of non-invasive imaging methods to assess RV structure, function, flow, and tissue characterization in the setting of imaging's contribution to the diagnostic, severity stratification, prognostic risk, response of treatment management, and disease surveillance implications of PH's impact on RH dysfunction and clinical RH failure.
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Affiliation(s)
- David J Hur
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States.,Division of Cardiology, Department of Medicine, Veterans Affairs Connecticut Healthcare System, West Haven, CT, United States
| | - Lissa Sugeng
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States.,Echocardiography Laboratory, Yale New Haven Hospital, New Haven, CT, United States
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Gesu E, Maria Rusconi A, Ceriani E. Five steps for the use and interpretation of D-dimer in the Emergency Department. Intern Emerg Med 2019; 14:311-314. [PMID: 30730033 DOI: 10.1007/s11739-019-02044-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Accepted: 01/29/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Elisa Gesu
- UOC Pronto Soccorso E Medicina D'Urgenza, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy.
| | - Anna Maria Rusconi
- S.C. Pronto Soccorso E Medicina D'Urgenza, Ospedale Santa Corona, ASL2 Savona, Pietra Ligure, Italy
| | - Elisa Ceriani
- Dipartimento Di Medicina Interna E Specializzazioni Mediche, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
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50
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Nagel SN, Steffen IG, Schwartz S, Hamm B, Elgeti T. Age-dependent diagnostic accuracy of clinical scoring systems and D-dimer levels in the diagnosis of pulmonary embolism with computed tomography pulmonary angiography (CTPA). Eur Radiol 2019; 29:4563-4571. [PMID: 30783786 DOI: 10.1007/s00330-019-06039-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 12/14/2018] [Accepted: 01/24/2019] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The aim of this study was to compare the age-dependent diagnostic performance of clinical scores and D-dimer testing to identify patients with suspected pulmonary embolism (PE). METHODS Consecutive patients with suspected PE referred from the emergency department for computed tomography pulmonary angiography (CTPA) were retrospectively evaluated. Diagnostic scores (classic Wells score (WS), modified WS, simplified WS, revised Geneva score (GS), simplified GS, and YEARS score) were calculated from medical records. Results of D-dimer testing were retrieved from the laboratory database. CTPA was the diagnostic reference standard. Four age groups were analyzed (< 50, 50-64, 65-74, and ≥ 75 years). Statistical analysis used receiver operating characteristics as well as uni- and multivariate analyses with calculation of prediction models. The study was IRB approved. RESULTS One thousand consecutive patients were included. Areas under the curve (AUC) and accuracies were superior in patients < 50 years. For the classic WS, the AUC decreased by 11% with the optimal cutoff dropping 1.5 points in patients ≥ 75 years; for D-dimer levels, the optimal cutoff was 900 μg/L higher in both ≥ 65 years groups with a max. decrease of the AUC of 9%. In terms of accuracy, the YEARS score performed best across all groups. Classic WS and D-dimer level showed a significant interaction with patient age in prediction models. CONCLUSION D-dimer measurement and clinical scores perform best in patients < 50 years. The YEARS score performs best across all age groups and is therefore recommended. KEY POINTS • The probability of pulmonary embolism predicted by fibrin fibrinogen degradation products and clinical scores shows the highest accuracy in patients < 50 years. • The probability of pulmonary embolism predicted by the YEARS score shows the highest accuracy in each age group. • Classic Wells score and fibrin fibrinogen degradation products show a significant interaction with patient age in a logistic regression model.
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Affiliation(s)
- Sebastian N Nagel
- Klinik und Hochschulambulanz für Radiologie, Charité - Universitätsmedizin Berlin Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany.
| | - Ingo G Steffen
- Klinik und Hochschulambulanz für Radiologie, Charité - Universitätsmedizin Berlin Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Stefan Schwartz
- Medizinische Klinik mit Schwerpunkt Hämatologie und Onkologie, Charité - Universitätsmedizin Berlin Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Bernd Hamm
- Klinik und Hochschulambulanz für Radiologie, Charité - Universitätsmedizin Berlin Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Thomas Elgeti
- Klinik und Hochschulambulanz für Radiologie, Charité - Universitätsmedizin Berlin Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
- Klinik für Nuklearmedizin, Charité - Universitätsmedizin Berlin Campus Virchow Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
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