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Huisman MV, Tromeur C, Gal GL, Roux PYL, Righini M. Diagnostic management of acute pulmonary embolism. Presse Med 2024:104241. [PMID: 39181236 DOI: 10.1016/j.lpm.2024.104241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/27/2024] Open
Abstract
Straightforward, accurate diagnostic management in patients presenting with clinically suspected pulmonary embolism (PE) is essential, since starting anticoagulant treatment may give important adverse effects of bleeding, while false exclusion of the disease may lead to recurrent VTE, with associated morbidity and mortality. In the past three decades, considerable improvement in the diagnostic management of PE has been made. Computed tomography pulmonary angiography (CTPA) has largely replaced conventional pulmonary angiography and ventilation-perfusion lung scanning as the imaging methods of choice. Several diagnostic algorithms, all able to minimize the need for radiological imaging have been developed and validated. Lastly, within the diagnostic algorithms, varying D-dimer cut-off levels have successfully been introduced to further downsize the need for radiological imaging.
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Affiliation(s)
- M V Huisman
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands; Dutch Thrombosis Network, Leiden, The Netherlands.
| | - C Tromeur
- Département de médecine interne, vasculaire et Pneumologie, CHU Brest; Univ Brest, INSERM U1304-GETBO, Brest, France
| | - G le Gal
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - P Y Le Roux
- Department of Nuclear Medicine, CHU Brest, Univ Brest, INSERM U1304-GETBO, Brest, France
| | - M Righini
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
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Valente Silva B, Jorge C, Plácido R, Nobre Menezes M, Mendonça C, Luísa Urbano M, Rigueira J, G Almeida A, Pinto FJ. Comparison of the accuracy of four diagnostic prediction rules for pulmonary embolism in patients admitted to the emergency department. Rev Port Cardiol 2024:S0870-2551(24)00106-9. [PMID: 38663529 DOI: 10.1016/j.repc.2024.02.006] [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: 05/10/2023] [Revised: 12/21/2023] [Accepted: 02/07/2024] [Indexed: 07/12/2024] Open
Abstract
INTRODUCTION AND OBJECTIVES Ruling out pulmonary embolism (PE) through a combination of clinical assessment and D-dimer level can potentially avoid excessive use of computed tomography pulmonary angiography (CTPA). We aimed to compare the diagnostic accuracy of the standard approach based on the Wells and Geneva scores combined with a standard D-dimer cut-off (500 ng/ml), with three alternative strategies (age-adjusted and the YEARS and PEGeD algorithms) in patients admitted to the emergency department (ED) with suspected PE. METHODS Consecutive outpatients admitted to the ED who underwent CTPA due to suspected PE were retrospectively assessed. Sensitivity, specificity, positive and negative predictive values, likelihood ratios and diagnostic odds ratios were calculated and compared between the different diagnostic prediction rules. RESULTS We included 1402 patients (mean age 69±18 years, 54% female), and PE was confirmed in 25%. Compared to the standard approach (p<0.001), an age-adjusted strategy increased specificity with a non-significant decrease in sensitivity only in patients older than 70 years. Compared to the standard and age-adjusted approaches, the YEARS and PEGeD algorithms had the highest specificity across all ages, but were associated with a significant decrease in sensitivity (p<0.001), particularly in patients aged under 60 years (sensitivity of 81% in patients aged between 51 and 60 years). CONCLUSION Compared to the standard approach, all algorithms were associated with increased specificity. The age-adjusted strategy was the only one not associated with a significant decrease in sensitivity compared to the standard approach, enabling CTPA requests to be reduced safely.
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Affiliation(s)
- Beatriz Valente Silva
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal.
| | - Cláudia Jorge
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Rui Plácido
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Miguel Nobre Menezes
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Carlos Mendonça
- Radiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
| | - Maria Luísa Urbano
- Radiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
| | - Joana Rigueira
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Ana G Almeida
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Fausto J Pinto
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
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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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Fan BE, Lippi G, Favaloro EJ. D-dimer Levels for the exclusion of pulmonary embolism: making sense of international guideline recommendations. J Thromb Haemost 2024; 22:604-608. [PMID: 38135252 DOI: 10.1016/j.jtha.2023.12.015] [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: 10/28/2023] [Revised: 12/07/2023] [Accepted: 12/07/2023] [Indexed: 12/24/2023]
Abstract
Several international guidelines provide recommendations around the use of D-dimer testing for exclusion of pulmonary embolism, including the appropriate D-dimer threshold (or cutoff), but there is no consensus among them. We briefly discuss guideline variation, performance characteristics, and limitations of commercially available D-dimer assays in this setting, referencing the Clinical and Laboratory Standards Institute guidelines that recommend immunoassays with high sensitivity (≥97%) and negative predictive value (≥98%). While age-adjusted D-dimer and pretest-adjusted D-dimer are considered a safe strategy across predefined patient subgroups, clinicians need to recognize the different performance characteristics of D-dimer assays to enable safe clinical decisions for their patients. Importantly, D-dimer values must be correlated not only to clinical findings but also interpreted within the context of the accuracy and precision of the specific testing modality, adhering to manufacturer specifications that are approved by regulatory authorities.
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Affiliation(s)
- Bingwen Eugene Fan
- Department of Haematology, Tan Tock Seng Hospital, Singapore; Department of Laboratory Medicine, Khoo Teck Puat Hospital, Singapore; Lee Kong Chian School of Medicine, Singapore; Yong Loo Lin School of Medicine, Singapore.
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
| | - Emmanuel J Favaloro
- Department of Haematology, Institute of Clinical Pathology and Medical Research, Sydney Centres for Thrombosis and Haemostasis, New South Wales Health Pathology, Westmead Hospital, Westmead, New South Wales, Australia; School of Dentistry and Medical Sciences, Faculty of Science and Health, Charles Sturt University, Wagga Wagga, Australia; School of Medical Sciences, Faculty of Medicine and Health, University of Sydney, Westmead Hospital, Westmead, New South Wales, Australia.
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Franco-Moreno A, Izquierdo-Martínez A, Pagai-Valcárcel I, Torres-Macho J, de Ancos-Aracil CL. CHEDDAR score versus YEARS algorithm for suspected pulmonary embolism in SARS-CoV-2-infected patients: A comparison of two strategies. Eur J Intern Med 2024; 119:129-131. [PMID: 37722931 DOI: 10.1016/j.ejim.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 09/02/2023] [Accepted: 09/07/2023] [Indexed: 09/20/2023]
Affiliation(s)
- Anabel Franco-Moreno
- Internal Medicine Department. Hospital Universitario Infanta Leonor-Virgen de la Torre, Madrid, Spain.
| | | | | | - Juan Torres-Macho
- Internal Medicine Department. Hospital Universitario Infanta Leonor-Virgen de la Torre, Madrid, Spain
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Huang J, Namazy J. Diagnosis and Management of Asthma in Pregnancy-Reply. JAMA 2023; 330:1589. [PMID: 37874576 DOI: 10.1001/jama.2023.15282] [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] [Indexed: 10/25/2023]
Affiliation(s)
- Jenny Huang
- Department of Allergy, Asthma, and Immunology, Scripps Clinic, San Diego, California
| | - Jennifer Namazy
- Department of Allergy, Asthma, and Immunology, Scripps Clinic, San Diego, California
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Robert-Ebadi H, Roy PM, Sanchez O, Verschuren F, Le Gal G, Righini M. External validation of the PEGeD diagnostic algorithm for suspected pulmonary embolism in an independent cohort. Blood Adv 2023; 7:3946-3951. [PMID: 36521170 PMCID: PMC10410134 DOI: 10.1182/bloodadvances.2022007729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 10/18/2022] [Accepted: 10/18/2022] [Indexed: 12/23/2022] Open
Abstract
Sequential diagnostic algorithms are used in the case of suspected pulmonary embolism (PE). The PEGeD study proposed a new diagnostic strategy to reduce the use of computed tomography pulmonary angiography (CTPA). We aimed to externally validate this diagnostic strategy in an independent cohort. We analyzed data from 3 prospective studies of outpatients with suspected PE. As per the PEGeD algorithm, patients were classified as having a low, moderate, or high clinical pretest probability (C-PTP). PE was excluded with a D-dimer <1000 ng/mL in case of low C-PTP and <500 ng/mL in case of moderate C-PTP. We assessed the yield and safety of this approach and compared them with those of previously validated algorithms. Among the 3308 evaluated patients, 1615 (49%) patients could have had PE excluded according to the PEGeD algorithm, without the need for imaging. Of these patients, 38 (2.3%; 95% confidence interval [CI], 1.7-3.2) were diagnosed with a symptomatic PE at initial testing or during the 3-month follow-up. On further analysis, 36 patients out of these 38 patients had a positive age-adjusted D-dimer. The risk of venous thromboembolic events among the 414 patients with a D-dimer <1000 ng/mL but above the age-adjusted D-dimer cut-off was 36 of 414 (8.7%; 95% CI, 6.4-11.8). We provide external validation of the PEGeD algorithm in an independent cohort. Compared with standard algorithms, the PEGeD decreased the number of CTPA examinations. However, caution is required in patients with a low C-PTP and a D-dimer <1000 ng/mL but above their age-adjusted D-dimer cut-off.
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Affiliation(s)
- Helia Robert-Ebadi
- Division of Angiology and Hemostasis and Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Pierre-Marie Roy
- Department of Emergency Medicine, University Hospital of Angers, Angers, France
| | - Olivier Sanchez
- Department of Respiratory Disease, Hôpital Européen Georges Pompidou, APHP, and Université Paris Descartes, Paris, France
| | - Frank Verschuren
- Emergency Department, Saint-Luc University Hospital, Brussels, Belgium
| | - Grégoire Le Gal
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Marc Righini
- Division of Angiology and Hemostasis and Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
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Helfer H, Skaff Y, Happe F, Djennaoui S, Chidiac J, Poénou G, Righini M, Mahé I. Diagnostic Approach for Venous Thromboembolism in Cancer Patients. Cancers (Basel) 2023; 15:cancers15113031. [PMID: 37296993 DOI: 10.3390/cancers15113031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 05/16/2023] [Accepted: 05/27/2023] [Indexed: 06/12/2023] Open
Abstract
Venous thromboembolic disease (VTE) is a common complication in cancer patients. The currently recommended VTE diagnostic approach involves a step-by-step algorithm, which is based on the assessment of clinical probability, D-dimer measurement, and/or diagnostic imaging. While this diagnostic strategy is well validated and efficient in the noncancer population, its use in cancer patients is less satisfactory. Cancer patients often present nonspecific VTE symptoms resulting in less discriminatory power of the proposed clinical prediction rules. Furthermore, D-dimer levels are often increased because of a hypercoagulable state associated with the tumor process. Consequently, the vast majority of patients require imaging tests. In order to improve VTE exclusion in cancer patients, several approaches have been developed. The first approach consists of ordering imaging tests to all patients, despite overexposing a population known to have mostly multiple comorbidities to radiations and contrast products. The second approach consists of new diagnostic algorithms based on clinical probability assessment with different D-dimer thresholds, e.g., the YEARS algorithm, which shows promise in improving the diagnosis of PE in cancer patients. The third approach uses an adjusted D-dimer threshold, to age, pretest probability, clinical criteria, or other criteria. These different diagnostic strategies have not been compared head-to-head. In conclusion, despite having several proposed diagnostic approaches to diagnose VTE in cancer patients, we still lack a dedicated diagnostic algorithm specific for this population.
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Affiliation(s)
- Hélène Helfer
- Service de Médecine Interne, Hôpital Louis Mourier, Assistance Publique des Hôpitaux de Paris (AP-HP), 92700 Colombes, France
- Université Paris Cité, 75006 Paris, France
- INSERM UMR-S-1140, 75006 Paris, France
| | - Yara Skaff
- Service de Médecine Interne, Hôpital Louis Mourier, Assistance Publique des Hôpitaux de Paris (AP-HP), 92700 Colombes, France
| | - Florent Happe
- Service de Médecine Interne, Hôpital Louis Mourier, Assistance Publique des Hôpitaux de Paris (AP-HP), 92700 Colombes, France
| | - Sadji Djennaoui
- Service de Médecine Interne, Hôpital Louis Mourier, Assistance Publique des Hôpitaux de Paris (AP-HP), 92700 Colombes, France
| | - Jean Chidiac
- Service de Médecine Interne, Hôpital Louis Mourier, Assistance Publique des Hôpitaux de Paris (AP-HP), 92700 Colombes, France
| | - Géraldine Poénou
- Service de Médecine Interne, Hôpital Louis Mourier, Assistance Publique des Hôpitaux de Paris (AP-HP), 92700 Colombes, France
| | - Marc Righini
- FCRIN INNOVTE, 42055 Saint-Étienne CEDEX 2, France
- Service d'Angiologie et Hémostase, HUG-Hôpitaux Universitaires de Genève, 1205 Genève, Switzerland
| | - Isabelle Mahé
- Service de Médecine Interne, Hôpital Louis Mourier, Assistance Publique des Hôpitaux de Paris (AP-HP), 92700 Colombes, France
- Université Paris Cité, 75006 Paris, France
- INSERM UMR-S-1140, 75006 Paris, France
- FCRIN INNOVTE, 42055 Saint-Étienne CEDEX 2, France
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Duffy J, Berger FH, Cheng I, Shelton D, Galanaud JP, Selby R, Laing K, Fedorovsky T, Matelski J, Hall J. Implementation of the YEARS algorithm to optimise pulmonary embolism diagnostic workup in the emergency department. BMJ Open Qual 2023; 12:bmjoq-2022-002119. [PMID: 37217241 DOI: 10.1136/bmjoq-2022-002119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 04/29/2023] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND Excessive use of CT pulmonary angiography (CTPA) to investigate pulmonary embolism (PE) in the emergency department (ED) contributes to adverse patient outcomes. Non-invasive D-dimer testing, in the context of a clinical algorithm, may help decrease unnecessary imaging but this has not been widely implemented in Canadian EDs. AIM To improve the diagnostic yield of CTPA for PE by 5% (absolute) within 12 months of implementing the YEARS algorithm. MEASURES AND DESIGN Single centre study of all ED patients >18 years investigated for PE with D-dimer and/or CTPA between February 2021 and January 2022. Primary and secondary outcomes were the diagnostic yield of CTPA and frequency of CTPA ordered compared with baseline. Process measures included the percentage of D-dimer tests ordered with CTPA and CTPAs ordered with D-dimers <500 µg/L Fibrinogen Equivalent Units (FEU). The balancing measure was the number of PEs identified on CTPA within 30 days of index visit. Multidisciplinary stakeholders developed plan- do-study-act cycles based on the YEARS algorithm. RESULTS Over 12 months, 2695 patients were investigated for PE, of which 942 had a CTPA. Compared with baseline, the CTPA yield increased by 2.9% (12.6% vs 15.5%, 95% CI -0.06% to 5.9%) and the proportion of patients that underwent CTPA decreased by 11.4% (46.4% vs 35%, 95% CI -14.1% to -8.8%). The percentage of CTPAs ordered with a D-dimer increased by 26.3% (30.7% vs 57%, 95% CI 22.2% 30.3%) and there were two missed PE (2/2695, 0.07%). IMPACT Implementing the YEARS criteria may safely improve the diagnostic yield of CTPAs and reduce the number of CTPAs completed without an associated increase in missed clinically significant PEs. This project provides a model for optimising the use of CTPA in the ED.
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Affiliation(s)
- Juliana Duffy
- Division of Emergency Medicine, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ferco Henricus Berger
- Department of Medical Imaging, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Ivy Cheng
- Division of Emergency Medicine, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Emergency Services, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Dominick Shelton
- Department of Emergency Services, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Family & Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jean-Philippe Galanaud
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Rita Selby
- Department of Laboratory Medicine & Pathobiology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Laboratory Medicine & Pathobiology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kristine Laing
- Department of Emergency Services, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Tali Fedorovsky
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - John Matelski
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Justin Hall
- Division of Emergency Medicine, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Emergency Services, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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de Wit K, Al-Haimus F, Hu Y, Ikesaka R, Chan N, Ibrahim Q, Klyn J, Clayton N, Germini F. Comparison of YEARS and Adjust-Unlikely D-dimer Testing for Pulmonary Embolism in the Emergency Department. Ann Emerg Med 2023; 81:558-565. [PMID: 36371248 DOI: 10.1016/j.annemergmed.2022.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 09/05/2022] [Accepted: 09/19/2022] [Indexed: 11/12/2022]
Abstract
STUDY OBJECTIVE We prospectively assessed the diagnostic accuracy of YEARS and a modified age-adjusted clinical decision rule ("Adjust-Unlikely") for pulmonary embolism (PE) testing in the emergency department. METHODS This study was conducted in tertiary care Canadian emergency departments. When the D-dimer was <500 ng/ml, PE was excluded. Pulmonary imaging for PE was performed when the D-dimer was ≥500 ng/ml. Patients were followed for 30 days, and PE outcomes were independently adjudicated. Physicians systematically recorded the presence or absence of YEARS items (PE most likely, hemoptysis, signs of deep venous thrombosis) prior to D-dimer testing and imaging. We analyzed the diagnostic accuracy of YEARS and the "Adjust-Unlikely" rule. Age adjustment (age x 10 in those >50 years old) was applied in patients where PE was not the most likely diagnosis and 500 ng/ml threshold when PE was most likely. RESULTS One thousand seven hundred three patients were included, median age 62 (50, 74), 58% female, PE prevalence 8.0%. YEARS sensitivity for PE diagnosis was 92.6% (87.0, 96.0%) and specificity 45.0% (42.5, 47.5%). Adjust-Unlikely sensitivity was 100.0% (97.2, 100.0%) and specificity 32.4% (30.1, 34.8%). Posttest probability of PE in the group of patients with PE excluded by D-dimer between 500 ng/ml and the adjusted limit was 2.8% (1.6, 5.1%) for YEARS and 0.0% (0.0, 2.6%) for the "Adjust-Unlikely" rule. CONCLUSION The "Adjust-Unlikely" rule would modestly reduce imaging and identify all cases of PE. YEARS would substantially reduce imaging but miss 1 in 14 cases of PE.
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Affiliation(s)
- Kerstin de Wit
- Department of Emergency Medicine and Medicine, Queens University, Kingston, and Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
| | - Fayad Al-Haimus
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Yang Hu
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Rick Ikesaka
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Noel Chan
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Quazi Ibrahim
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Joshua Klyn
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Natasha Clayton
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Emergency Department, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Federico Germini
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, ON, Canada
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Luu IHY, Frijns T, Buijs J, Krdzalic J, de Kruif MD, Mostard GJM, Ten Cate H, Martens RJH, Mostard RLM, Leers MPG, van Twist DJL. Systematic screening versus clinical gestalt in the diagnosis of pulmonary embolism in COVID-19 patients in the emergency department. PLoS One 2023; 18:e0283459. [PMID: 36952456 PMCID: PMC10035852 DOI: 10.1371/journal.pone.0283459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 03/03/2023] [Indexed: 03/25/2023] Open
Abstract
BACKGROUND Diagnosing concomitant pulmonary embolism (PE) in COVID-19 patients remains challenging. As such, PE may be overlooked. We compared the diagnostic yield of systematic PE-screening based on the YEARS-algorithm to PE-screening based on clinical gestalt in emergency department (ED) patients with COVID-19. METHODS We included all ED patients who were admitted because of COVID-19 between March 2020 and February 2021. Patients already receiving anticoagulant treatment were excluded. Up to April 7, 2020, the decision to perform CT-pulmonary angiography (CTPA) was based on physician's clinical gestalt (clinical gestalt cohort). From April 7 onwards, systematic PE-screening was performed by CTPA if D-dimer level was ≥1000 ug/L, or ≥500 ug/L in case of ≥1 YEARS-item (systematic screening cohort). RESULTS 1095 ED patients with COVID-19 were admitted. After applying exclusion criteria, 289 were included in the clinical gestalt and 574 in the systematic screening cohort. The number of PE diagnoses was significantly higher in the systematic screening cohort compared to the clinical gestalt cohort: 8.2% vs. 1.0% (3/289 vs. 47/574; p<0.001), even after adjustment for differences in patient characteristics (adjusted OR 8.45 (95%CI 2.61-27.42, p<0.001) for PE diagnosis). In multivariate analysis, D-dimer (OR 1.09 per 1000 μg/L increase, 95%CI 1.06-1.13, p<0.001) and CRP >100 mg/L (OR 2.78, 95%CI 1.37-5.66, p = 0.005) were independently associated with PE. CONCLUSION In ED patients with COVID-19, the number of PE diagnosis was significantly higher in the cohort that underwent systematic PE screening based on the YEARS-algorithm in comparison with the clinical gestalt cohort, with a number needed to test of 7.1 CTPAs to detect one PE.
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Affiliation(s)
- Inge H Y Luu
- Department of Internal Medicine, Zuyderland Medical Centre, Sittard/Heerlen, The Netherlands
| | - Tim Frijns
- Department of Internal Medicine, Zuyderland Medical Centre, Sittard/Heerlen, The Netherlands
| | - Jacqueline Buijs
- Department of Internal Medicine, Zuyderland Medical Centre, Sittard/Heerlen, The Netherlands
| | - Jasenko Krdzalic
- Department of Radiology, Zuyderland Medical Centre, Sittard/Heerlen, The Netherlands
| | - Martijn D de Kruif
- Department of Pulmonology, Zuyderland Medical Centre, Sittard/Heerlen, The Netherlands
| | - Guy J M Mostard
- Department of Internal Medicine, Zuyderland Medical Centre, Sittard/Heerlen, The Netherlands
| | - Hugo Ten Cate
- Department of Internal Medicine and Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Remy J H Martens
- Department of Clinical Chemistry and Haematology, Zuyderland Medical Centre, Sittard/Heerlen, The Netherlands
| | - Remy L M Mostard
- Department of Pulmonology, Zuyderland Medical Centre, Sittard/Heerlen, The Netherlands
| | - Math P G Leers
- Department of Clinical Chemistry and Haematology, Zuyderland Medical Centre, Sittard/Heerlen, The Netherlands
| | - Daan J L van Twist
- Department of Internal Medicine, Zuyderland Medical Centre, Sittard/Heerlen, The Netherlands
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Hillegass E, Lukaszewicz K, Puthoff M. Role of Physical Therapists in the Management of Individuals at Risk for or Diagnosed With Venous Thromboembolism: Evidence-Based Clinical Practice Guideline 2022. Phys Ther 2022; 102:6585463. [PMID: 35567347 DOI: 10.1093/ptj/pzac057] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 01/24/2022] [Accepted: 02/22/2022] [Indexed: 11/14/2022]
Abstract
No matter the practice setting, physical therapists work with patients who are at risk for or who have a history of venous thromboembolism (VTE). In 2016, the first clinical practice guideline (CPG) addressing the physical therapist management of VTE was published with support by the American Physical Therapy Association's Academy of Cardiovascular and Pulmonary Physical Therapy and Academy of Acute Care, with a primary focus on lower extremity deep vein thrombosis (DVT). This CPG is an update of the 2016 CPG and contains the most current evidence available for the management of patients with lower extremity DVT and new key action statements (KAS), including guidance on upper extremity DVT, pulmonary embolism, and special populations. This document will guide physical therapist practice in the prevention of and screening for VTE and in the management of patients who are at risk for or who have been diagnosed with VTE. Through a systematic review of published studies and a structured appraisal process, KAS were written to guide the physical therapist. The evidence supporting each action was rated, and the strength of statement was determined. Clinical practice algorithms based on the KAS were developed that can assist with clinical decision-making. Physical therapists, along with other members of the health care team, should implement these KAS to decrease the incidence of VTE, improve the diagnosis and acute management of VTE, and reduce the long-term complications of VTE.
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Affiliation(s)
- Ellen Hillegass
- Department of Physical Therapy, Mercer University, Atlanta, Georgia, USA
| | | | - Michael Puthoff
- Physical Therapy Department, St Ambrose University, Davenport, Iowa, USA
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13
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Cafferkey J, Serebriakoff P, de Wit K, Horner DE, Reed MJ. Pulmonary embolism diagnosis: clinical assessment at the front door. J Accid Emerg Med 2022; 39:945-951. [PMID: 35868848 DOI: 10.1136/emermed-2021-212000] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 07/09/2022] [Indexed: 11/03/2022]
Abstract
This first of two practice reviews addresses pulmonary embolism (PE) diagnosis considering important aspects of PE clinical presentation and comparing evidence-based PE testing strategies. A companion paper addresses the management of PE. Symptoms and signs of PE are varied, and emergency physicians frequently use testing to 'rule out' the diagnosis in people with respiratory or cardiovascular symptoms. The emergency clinician must balance the benefit of reassuring negative PE testing with the risks of iatrogenic harms from over investigation and overdiagnosis.
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Affiliation(s)
- John Cafferkey
- Emergency Medicine Research Group Edinburgh (EMERGE), NHS Lothian, Edinburgh, UK
| | | | - Kerstin de Wit
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada.,Department of Medicine, McMaster University, Ontario, Canada
| | - Daniel E Horner
- Emergency Department, Salford Royal NHS Foundation Trust, Salford, UK.,Division of Infection, Immunity and Respiratory Medicine, The University of Manchester, Manchester, UK
| | - Matthew James Reed
- Emergency Medicine Research Group Edinburgh (EMERGE), NHS Lothian, Edinburgh, UK .,Acute Care Group, The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
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14
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Roy PM, Friou E, Germeau B, Douillet D, Kline JA, Righini M, Le Gal G, Moumneh T, Penaloza A. Derivation and Validation of a 4-Level Clinical Pretest Probability Score for Suspected Pulmonary Embolism to Safely Decrease Imaging Testing. JAMA Cardiol 2021; 6:669-677. [PMID: 33656522 PMCID: PMC7931139 DOI: 10.1001/jamacardio.2021.0064] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance In patients with suspected pulmonary embolism (PE), overuse of diagnostic imaging is an important point of concern. Objective To derive and validate a 4-level pretest probability rule (4-Level Pulmonary Embolism Clinical Probability Score [4PEPS]) that makes it possible to rule out PE solely on clinical criteria and optimized D-dimer measurement to safely decrease imaging testing for suspected PE. Design, Setting, and Participants This study included consecutive outpatients suspected of having PE from US and European emergency departments. Individual data from 3 merged management studies (n = 11 114; overall prevalence of PE, 11%) were used for the derivation cohort and internal validation cohort. The external validation cohorts were taken from 2 independent studies, the first with a high PE prevalence (n = 1548; prevalence, 21.5%) and the second with a moderate PE prevalence (n = 1669; prevalence, 11.7%). A prior definition of pretest probability target values to achieve a posttest probability less than 2% was used on the basis of the negative likelihood ratios of D-dimer. Data were collected from January 2003 to April 2016, and data were analyzed from June 2018 to August 2019. Main Outcomes and Measures The rate of PE diagnosed during the initial workup or during follow-up and the rate of imaging testing. Results Of the 5588 patients in the derivation cohort, 3441 (61.8%) were female, and the mean (SD) age was 52 (18.5) years. The 4PEPS comprises 13 clinical variables scored from -2 to 5. It results in the following strategy: (1) very low probability of PE if 4PEPS is less than 0: PE ruled out without testing; (2) low probability of PE if 4PEPS is 0 to 5: PE ruled out if D-dimer level is less than 1.0 μg/mL; (3) moderate probability of PE if 4PEPS is 6 to 12: PE ruled out if D-dimer level is less than the age-adjusted cutoff value; (4) high probability of PE if 4PEPS is greater than 12: PE ruled out by imaging without preceding D-dimer test. In the first and the second external validation cohorts, the area under the receiver operator characteristic curves were 0.79 (95% CI, 0.76 to 0.82) and 0.78 (95% CI, 0.74 to 0.81), respectively. The false-negative testing rates if the 4PEPS strategy had been applied were 0.71% (95% CI, 0.37 to 1.23) and 0.89% (95% CI, 0.53 to 1.49), respectively. The absolute reductions in imaging testing were -22% (95% CI, -26 to -19) and -19% (95% CI, -22 to -16) in the first and second external validation cohorts, respectively. The 4PEPS strategy compared favorably with all recent strategies in terms of imaging testing. Conclusions and Relevance The 4PEPS strategy may lead to a substantial and safe reduction in imaging testing for patients with suspected PE. It should now be tested in a formal outcome study.
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Affiliation(s)
- Pierre-Marie Roy
- Emergency Department, CHU Angers, Institut Mitovasc UMR (CNRS 6015-INSERM 1083), UNIV Angers, F-CRIN INNOVTE, Angers, France
| | - Emilie Friou
- Emergency Department, CHU Angers, Angers, France
| | - Boris Germeau
- Emergency Department, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Delphine Douillet
- Emergency Department, CHU Angers, Institut Mitovasc UMR (CNRS 6015-INSERM 1083), UNIV Angers, F-CRIN INNOVTE, Angers, France
| | - Jeffrey Allen Kline
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis
| | - Marc Righini
- Division of Angiology and Hemostasis, Department of Internal Medicine, Faculty of Medicine, Geneva University Hospital, Geneva, Switzerland
| | - Grégoire Le Gal
- Ottawa Hospital Research Institute, The Ottawa Hospital, Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Thomas Moumneh
- Emergency Department, CHU Angers, Institut Mitovasc UMR (CNRS 6015-INSERM 1083), UNIV Angers, F-CRIN INNOVTE, Angers, France
| | - Andrea Penaloza
- Emergency Department, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, F-CRIN INNOVTE, Brussels, Belgium
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Douillet D, Roy PM, Penaloza A. Suspected Acute Pulmonary Embolism: Gestalt, Scoring Systems, and Artificial Intelligence. Semin Respir Crit Care Med 2021; 42:176-182. [PMID: 33592653 DOI: 10.1055/s-0041-1723936] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Pulmonary embolism (PE) remains a diagnostic challenge in 2021. As the pathology is potentially fatal and signs and symptoms are nonspecific, further investigations are classically required. Based on the Bayesian approach, clinical probability became the keystone of the diagnostic strategy to rule out PE in the case of a negative testing. Several clinical probability assessment methods are validated: gestalt, the Wells score, or the revised Geneva score. While the debate persists as to the best way to assess clinical probability, its assessment allows for the good interpretation of the investigation results and therefore directs the correct diagnostic strategy. The wide availability of computed tomography pulmonary angiography (CTPA) resulted in a major increase in investigations with a moderate increase in diagnosis, without any notable improvement in patient outcomes. This leads to a new challenge for PE diagnosis which is the limitation of the number of testing for suspected PE. We review different strategies recently developed to achieve this goal. The last challenge concerns the implementation in clinical practice. Two approaches are developed: simplification of the strategies versus the use of digital support tools allowing more sophisticated strategies. Artificial intelligence with machine-learning algorithms will probably be a future tool to guide the physician in this complex approach concerning acute PE suspicion.
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Affiliation(s)
- Delphine Douillet
- Emergency Department, Angers University Hospital, INSERM 1083, Health Faculty, UNIV Angers, F-CRIN INNOVTE, Angers, France
| | - Pierre-Marie Roy
- Emergency Department, Angers University Hospital, INSERM 1083, Health Faculty, UNIV Angers, F-CRIN INNOVTE, Angers, France
| | - Andrea Penaloza
- Emergency Department, Cliniques Universitaires Saint Luc, UCLouvain, F-CRIN INNOVTE, Brussels, Belgium
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