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van Maanen R, Martens ESL, Takada T, Roy PM, de Wit K, Parpia S, Kraaijpoel N, Huisman MV, Wells PS, Le Gal G, Righini M, Freund Y, Galipienzo J, van Es N, Blom JW, Moons KGM, Rutten FH, van Smeden M, Klok FA, Geersing GJ, Luijken K. Accuracy of physicians' intuitive risk estimation in the diagnostic management of pulmonary embolism: an individual patient data meta-analysis. J Thromb Haemost 2023; 21:2873-2883. [PMID: 37263381 DOI: 10.1016/j.jtha.2023.05.023] [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: 01/27/2023] [Revised: 05/04/2023] [Accepted: 05/23/2023] [Indexed: 06/03/2023]
Abstract
BACKGROUND In patients clinically suspected of having pulmonary embolism (PE), physicians often rely on intuitive estimation ("gestalt") of PE presence. Although shown to be predictive, gestalt is criticized for its assumed variation across physicians and lack of standardization. OBJECTIVES To assess the diagnostic accuracy of gestalt in the diagnosis of PE and gain insight into its possible variation. METHODS We performed an individual patient data meta-analysis including patients suspected of having PE. The primary outcome was diagnostic accuracy of gestalt for the diagnosis of PE, quantified as risk ratio (RR) between gestalt and PE based on 2-stage random-effect log-binomial meta-analysis regression as well as gestalts' sensitivity and specificity. The variability of these measures was explored across different health care settings, publication period, PE prevalence, patient subgroups (sex, heart failure, chronic lung disease, and items of the Wells score other than gestalt), and age. RESULTS We analyzed 20 770 patients suspected of having PE from 16 original studies. The prevalence of PE in patients with and without a positive gestalt was 28.8% vs 9.1%, respectively. The overall RR was 3.02 (95% CI, 2.35-3.87), and the overall sensitivity and specificity were 74% (95% CI, 68%-79%) and 61% (95% CI, 53%-68%), respectively. Although variation was observed across individual studies (I2, 90.63%), the diagnostic accuracy was consistent across all subgroups and health care settings. CONCLUSION A positive gestalt was associated with a 3-fold increased risk of PE in suspected patients. Although variation was observed across studies, the RR of gestalt was similar across prespecified subgroups and health care settings, exemplifying its diagnostic value for all patients suspected of having PE.
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Affiliation(s)
- Rosanne van Maanen
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
| | - Emily S L Martens
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands. https://twitter.com/ESLmartens
| | - Toshihiko Takada
- Department of General Medicine, Shirakawa Satellite for Teaching And Research (STAR), Fukushima Medical University, Fukushima, Japan
| | - Pierre-Marie Roy
- Department of Emergency Medicine, Angers University Hospital; MitoVasc UMR CNRS 6015 - INSERM 1083, Université Angers, Angers; and French Clinical Research Infrastructure (F-CRIN) Network, INvestigation Network On Venous Thrombo-Embolism (INNOVTE), Saint-Etienne, France
| | - Kerstin de Wit
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; Department of Emergency Medicine, Queen's University, Kingston, Canada
| | - Sameer Parpia
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; Department of Oncology, McMaster University, Hamilton, Canada
| | - Noémie Kraaijpoel
- Department of Medicine, Amsterdam University Medical Center, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Philip S Wells
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Grégoire Le Gal
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Yonathan Freund
- Sorbonne University, Emergency Department, Hopital Pitie-Salpêtrière, Assistance Publique-Hopitaux de Paris, Paris, France
| | - Javier Galipienzo
- Service of Anesthesiology, MD Anderson Cancer Center Madrid, Madrid, Spain
| | - Nick van Es
- Amsterdam UMC location University of Amsterdam, Department of Vascular Medicine, Meibergdreef 9, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension & Thrombosis, Amsterdam, the Netherlands
| | - Jeanet W Blom
- Department of General Practice, Leiden University Medical Center, Leiden, the Netherlands
| | - Karel G M Moons
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Frans H Rutten
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Maarten van Smeden
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Geert-Jan Geersing
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Kim Luijken
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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2
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van Es N, Takada T, Kraaijpoel N, Klok FA, Stals MAM, Büller HR, Courtney DM, Freund Y, Galipienzo J, Le Gal G, Ghanima W, Huisman MV, Kline JA, Moons KGM, Parpia S, Perrier A, Righini M, Robert-Ebadi H, Roy PM, Wells PS, de Wit K, van Smeden M, Geersing GJ. Diagnostic management of acute pulmonary embolism: a prediction model based on a patient data meta-analysis. Eur Heart J 2023; 44:3073-3081. [PMID: 37452732 PMCID: PMC10917087 DOI: 10.1093/eurheartj/ehad417] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 04/25/2023] [Accepted: 06/13/2023] [Indexed: 07/18/2023] Open
Abstract
AIMS Risk stratification is used for decisions regarding need for imaging in patients with clinically suspected acute pulmonary embolism (PE). The aim was to develop a clinical prediction model that provides an individualized, accurate probability estimate for the presence of acute PE in patients with suspected disease based on readily available clinical items and D-dimer concentrations. METHODS AND RESULTS An individual patient data meta-analysis was performed based on sixteen cross-sectional or prospective studies with data from 28 305 adult patients with clinically suspected PE from various clinical settings, including primary care, emergency care, hospitalized and nursing home patients. A multilevel logistic regression model was built and validated including ten a priori defined objective candidate predictors to predict objectively confirmed PE at baseline or venous thromboembolism (VTE) during follow-up of 30 to 90 days. Multiple imputation was used for missing data. Backward elimination was performed with a P-value <0.10. Discrimination (c-statistic with 95% confidence intervals [CI] and prediction intervals [PI]) and calibration (outcome:expected [O:E] ratio and calibration plot) were evaluated based on internal-external cross-validation. The accuracy of the model was subsequently compared with algorithms based on the Wells score and D-dimer testing. The final model included age (in years), sex, previous VTE, recent surgery or immobilization, haemoptysis, cancer, clinical signs of deep vein thrombosis, inpatient status, D-dimer (in µg/L), and an interaction term between age and D-dimer. The pooled c-statistic was 0.87 (95% CI, 0.85-0.89; 95% PI, 0.77-0.93) and overall calibration was very good (pooled O:E ratio, 0.99; 95% CI, 0.87-1.14; 95% PI, 0.55-1.79). The model slightly overestimated VTE probability in the lower range of estimated probabilities. Discrimination of the current model in the validation data sets was better than that of the Wells score combined with a D-dimer threshold based on age (c-statistic 0.73; 95% CI, 0.70-0.75) or structured clinical pretest probability (c-statistic 0.79; 95% CI, 0.76-0.81). CONCLUSION The present model provides an absolute, individualized probability of PE presence in a broad population of patients with suspected PE, with very good discrimination and calibration. Its clinical utility needs to be evaluated in a prospective management or impact study. REGISTRATION PROSPERO ID 89366.
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Affiliation(s)
- Nick van Es
- Amsterdam University Medical Center, Department of Vascular Medicine, University of Amsterdam, Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension & Thrombosis, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Toshihiko Takada
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Universiteitsweg 100, 3584 CG, Utrecht, The Netherlands
- Department of General Medicine, Shirakawa Satellite for Teaching And Research (STAR), Fukushima Medical University, 1 Hikarigaoka, Fukushima, 960-1247, Japan
| | - Noémie Kraaijpoel
- Amsterdam University Medical Center, Department of Vascular Medicine, University of Amsterdam, Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension & Thrombosis, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Frederikus A Klok
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, Zuid-Holland, The Netherlands
| | - Milou A M Stals
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, Zuid-Holland, The Netherlands
| | - Harry R Büller
- Amsterdam University Medical Center, Department of Vascular Medicine, University of Amsterdam, Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension & Thrombosis, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - D Mark Courtney
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA
| | - Yonathan Freund
- Emergency Department, Sorbonne University, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Bd de l'Hôpital, 75013 Paris, France
| | - Javier Galipienzo
- Service of Anesthesiology, MD Anderson Cancer Center Madrid, C. de Arturo Soria, 270, 28033 Madrid, Spain
| | - Grégoire Le Gal
- Department of Medicine, University of Ottawa, and the Ottawa Hospital Research Institute, 725 Parkdale Ave, Ottawa, ON K1Y 4E9, Canada
| | - Waleed Ghanima
- Departments of Hemato-oncology and Research, Østfold hospital, Kalnesveien 300, 1714 Grålum, Norway
- Institute of Clinical Medicine, University of Oslo, Klaus Torgårds vei 3, 0372 Oslo, Oslo, Norway
| | - Menno V Huisman
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, Zuid-Holland, The Netherlands
| | - Jeffrey A Kline
- Department of Emergency Medicine, Wayne State University School of Medicine, 540 E Canfield St, Detroit, MI 4820, USA
| | - Karel G M Moons
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Universiteitsweg 100, 3584 CG, Utrecht, The Netherlands
| | - Sameer Parpia
- Department of Health Research Methods, Evidence, & Impact, McMaster University, 1200 Main St W, Hamilton, ON L8N 3Z5, Canada
- Department of Oncology, McMaster University, Juravinski Cancer Centre, 699 Concession St. Suite 4-204, Hamilton, Ontario, Canada
| | - Arnaud Perrier
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Rue Michel-Servet 1, 1206 Genève, Switzerland
| | - Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Rue Michel-Servet 1, 1206 Genève, Switzerland
| | - Helia Robert-Ebadi
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Rue Michel-Servet 1, 1206 Genève, Switzerland
| | - Pierre-Marie Roy
- Emergency Department, CHU Angers, UNIV Angers, 4 Rue Larrey, 49100 Angers, Maine-et-Loire, France
| | - Phil S Wells
- Department of Medicine, University of Ottawa, and the Ottawa Hospital Research Institute, 725 Parkdale Ave, Ottawa, ON K1Y 4E9, Canada
| | - Kerstin de Wit
- Department of Emergency Medicine, Queen's University, 76 Stuart Street, Kingston ON K7L 2V7, Canada
- Department of Medicine, McMaster University, McMaster Children's Hospital, 1200 Main Street West, Hamilton, L8N 3Z5 Ontario, Canada
- Department of Health Evidence and Impact, McMaster University, 1200 Main St W, Hamilton, ON L8N 3Z5, Canada
| | - Maarten van Smeden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Universiteitsweg 100, 3584 CG, Utrecht, The Netherlands
| | - Geert-Jan Geersing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Universiteitsweg 100, 3584 CG, Utrecht, The Netherlands
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Stals MAM, Takada T, Kraaijpoel N, van Es N, Büller HR, Courtney DM, Freund Y, Galipienzo J, Le Gal G, Ghanima W, Huisman MV, Kline JA, Moons KGM, Parpia S, Perrier A, Righini M, Robert-Ebadi H, Roy PM, van Smeden M, Wells PS, de Wit K, Geersing GJ, Klok FA. Safety and Efficiency of Diagnostic Strategies for Ruling Out Pulmonary Embolism in Clinically Relevant Patient Subgroups : A Systematic Review and Individual-Patient Data Meta-analysis. Ann Intern Med 2022; 175:244-255. [PMID: 34904857 DOI: 10.7326/m21-2625] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND How diagnostic strategies for suspected pulmonary embolism (PE) perform in relevant patient subgroups defined by sex, age, cancer, and previous venous thromboembolism (VTE) is unknown. PURPOSE To evaluate the safety and efficiency of the Wells and revised Geneva scores combined with fixed and adapted D-dimer thresholds, as well as the YEARS algorithm, for ruling out acute PE in these subgroups. DATA SOURCES MEDLINE from 1 January 1995 until 1 January 2021. STUDY SELECTION 16 studies assessing at least 1 diagnostic strategy. DATA EXTRACTION Individual-patient data from 20 553 patients. DATA SYNTHESIS Safety was defined as the diagnostic failure rate (the predicted 3-month VTE incidence after exclusion of PE without imaging at baseline). Efficiency was defined as the proportion of individuals classified by the strategy as "PE considered excluded" without imaging tests. Across all strategies, efficiency was highest in patients younger than 40 years (47% to 68%) and lowest in patients aged 80 years or older (6.0% to 23%) or patients with cancer (9.6% to 26%). However, efficiency improved considerably in these subgroups when pretest probability-dependent D-dimer thresholds were applied. Predicted failure rates were highest for strategies with adapted D-dimer thresholds, with failure rates varying between 2% and 4% in the predefined patient subgroups. LIMITATIONS Between-study differences in scoring predictor items and D-dimer assays, as well as the presence of differential verification bias, in particular for classifying fatal events and subsegmental PE cases, all of which may have led to an overestimation of the predicted failure rates of adapted D-dimer thresholds. CONCLUSION Overall, all strategies showed acceptable safety, with pretest probability-dependent D-dimer thresholds having not only the highest efficiency but also the highest predicted failure rate. From an efficiency perspective, this individual-patient data meta-analysis supports application of adapted D-dimer thresholds. PRIMARY FUNDING SOURCE Dutch Research Council. (PROSPERO: CRD42018089366).
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Affiliation(s)
- Milou A M Stals
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands (M.A.M.S., M.V.H., F.A.K.)
| | - Toshihiko Takada
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands, and Department of General Medicine, Shirakawa Satellite for Teaching and Research (STAR), Fukushima Medical University, Fukushima, Japan (T.T.)
| | - Noémie Kraaijpoel
- Department of Vascular Medicine, Amsterdam University Medical Center, location AMC, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands (N.K., N.v.E., H.R.B.)
| | - Nick van Es
- Department of Vascular Medicine, Amsterdam University Medical Center, location AMC, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands (N.K., N.v.E., H.R.B.)
| | - Harry R Büller
- Department of Vascular Medicine, Amsterdam University Medical Center, location AMC, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands (N.K., N.v.E., H.R.B.)
| | - D Mark Courtney
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas (D.M.C.)
| | - Yonathan Freund
- Department of Emergency Medicine, Pitié-Salpêtrière University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France (Y.F.)
| | - Javier Galipienzo
- Service of Anesthesiology, Hospital MD Anderson Cancer Center, Madrid, Spain (J.G.)
| | - Grégoire Le Gal
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Thrombosis Research Group, Ottawa, Ontario, Canada (G.L.G., P.S.W.)
| | - Waleed Ghanima
- Department of Medicine, Østfold Hospital Trust and Institute of Clinical Medicine, University of Oslo, Oslo, Norway (W.G.)
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands (M.A.M.S., M.V.H., F.A.K.)
| | - Jeffrey A Kline
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana (J.A.K.)
| | - Karel G M Moons
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands (K.G.M.M., M.v.S., G.J.G.)
| | - Sameer Parpia
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada (S.P.)
| | - Arnaud Perrier
- Division of Angiology and Hemostasis, Department of Medical Specialties, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland (A.P., M.R., H.R.E.)
| | - Marc Righini
- Division of Angiology and Hemostasis, Department of Medical Specialties, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland (A.P., M.R., H.R.E.)
| | - Helia Robert-Ebadi
- Division of Angiology and Hemostasis, Department of Medical Specialties, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland (A.P., M.R., H.R.E.)
| | - Pierre-Marie Roy
- Department of Emergency Medicine, University of Angers, Angers, France (P.M.R.)
| | - Maarten van Smeden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands (K.G.M.M., M.v.S., G.J.G.)
| | - Phil S Wells
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Thrombosis Research Group, Ottawa, Ontario, Canada (G.L.G., P.S.W.)
| | - Kerstin de Wit
- Department of Emergency Medicine, Queen's University, Kingston, and Departments of Medicine and Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario, Canada (K.d.W.)
| | - Geert-Jan Geersing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands (K.G.M.M., M.v.S., G.J.G.)
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands (M.A.M.S., M.V.H., F.A.K.)
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Germini F, Zarabi S, Eventov M, Turcotte M, Li M, de Wit K. Pulmonary embolism prevalence among emergency department cohorts: A systematic review and meta-analysis by country of study. J Thromb Haemost 2021; 19:173-185. [PMID: 33048461 DOI: 10.1111/jth.15124] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 09/08/2020] [Accepted: 09/28/2020] [Indexed: 12/30/2022]
Abstract
Essentials The threshold to test for pulmonary embolism (PE) might be lower in North America than Europe. We compared the PE prevalence and positive yield of imaging in Europe and North America. More patients tested in Europe are diagnosed with PE, and imaging is more often positive. Our systematic review supports the hypothesis of overtesting for PE in North America. ABSTRACT: Background There is an impression that North American emergency department (ED) patients tested for pulmonary embolism (PE) differ from European ones. Objectives We compared the PE prevalence, frequency of use, and positive yield of imaging among ED patients tested for PE in Europe and North America. Methods We searched for studies reporting consecutive ED patients tested for PE. Two authors screened full texts, performed risk of bias assessment, and data extraction. We conducted a meta-analysis of proportions for each outcome and a multiple meta-regression. Results From 3109 publications, 44 were included in the systematic review. The prevalence of PE in Europe was 23% (95% confidence interval [CI], 21-26) and in North America 8% (95% CI, 6-9). The adjusted mean difference (aMD) in the prevalence of PE in the European compared with North American studies, was 15% (95% CI, 10-20). Computed tomography pulmonary angiography (CTPA) was used in 60% (95% CI, 52%-68) of European and 38% (95% CI, 24-51) of North American patients tested for PE (aMD, 23% [95% CI, 7-39]). The CTPA diagnostic yield was 29% (95% CI, 26-32) in Europe and 13% (95% CI, 9-17) in North America (aMD, 15% [95% CI, 8-21]). Conclusion Compared with North America, European ED studies have a higher prevalence of PE and diagnostic yield from CTPA, despite a higher frequency of CTPA use among patients tested for PE. This supports the hypothesis that those tested for PE in North American EDs have a lower risk of PE compared with Europe.
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Affiliation(s)
- Federico Germini
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Canada
- Department of Health Sciences, Università degli Studi di Milano, Milano, Italy
| | - Sahar Zarabi
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Canada
| | - Michelle Eventov
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Canada
| | - Michelle Turcotte
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Canada
| | - Meirui Li
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Canada
| | - Kerstin de Wit
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Canada
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5
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Diagnosis and Exclusion of Pulmonary Embolism. Thromb Res 2018; 163:207-220. [DOI: 10.1016/j.thromres.2017.06.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Revised: 05/30/2017] [Accepted: 06/05/2017] [Indexed: 12/21/2022]
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Schols AMR, Stakenborg JPG, Dinant GJ, Willemsen RTA, Cals JWL. Point-of-care testing in primary care patients with acute cardiopulmonary symptoms: a systematic review. Fam Pract 2018; 35:4-12. [PMID: 28985344 DOI: 10.1093/fampra/cmx066] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Point-of-care tests (POCT) can assist general practitioners (GPs) in diagnosing and treating patients with acute cardiopulmonary symptoms, but it is currently unknown if POCT impact relevant clinical outcomes in these patients. OBJECTIVE To assess whether using POCT in primary care patients with acute cardiopulmonary symptoms leads to more accurate diagnosis and impacts clinical management. METHODS We performed a systematic review in four bibliographic databases. Articles published before February 2016 were screened by two reviewers. Studies evaluating the effect of GP use of POCT on clinical diagnostic accuracy and/or effect on treatment and referral rate in patients with cardiopulmonary symptoms were included. RESULTS Our search yielded nine papers describing data from seven studies, on the clinical diagnostic accuracy of POCT in a total of 2277 primary care patients with acute cardiopulmonary symptoms. Four papers showed data on GP use of D-dimer POCT in pulmonary embolism (two studies); two studies on Troponin T in acute coronary syndrome; one on heart-type fatty acid-binding protein (H-FABP) in acute coronary syndrome; one on B-type natriuretic peptide (BNP) in heart failure; one on 3-in-1 POCT (Troponin T, BNP, D-dimer) in acute coronary syndrome, heart failure and/or pulmonary embolism. Only one study assessed the effect of GP use of POCT on treatment initiation and one on actual referral rates. CONCLUSION There is currently limited and inconclusive evidence that actual GP use of POCT in primary care patients with acute cardiopulmonary symptoms leads to more accurate diagnosis and affects clinical management. However, some studies show promising results, especially when a POCT is combined with a clinical decision rule.
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Affiliation(s)
- Angel M R Schols
- Department of Family Medicine, School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Jacqueline P G Stakenborg
- Department of Family Medicine, School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Geert-Jan Dinant
- Department of Family Medicine, School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Robert T A Willemsen
- Department of Family Medicine, School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Jochen W L Cals
- Department of Family Medicine, School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, The Netherlands
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7
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Emergency Evaluation for Pulmonary Embolism, Part 2: Diagnostic Approach. J Emerg Med 2015; 49:104-17. [DOI: 10.1016/j.jemermed.2014.12.041] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 12/17/2014] [Accepted: 12/21/2014] [Indexed: 12/14/2022]
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8
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Lucassen WAM, Erkens PMG, Geersing GJ, Büller HR, Moons KGM, Stoffers HEJH, van Weert HCPM. Qualitative point-of-care D-dimer testing compared with quantitative D-dimer testing in excluding pulmonary embolism in primary care. J Thromb Haemost 2015; 13:1004-9. [PMID: 25845618 DOI: 10.1111/jth.12951] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 03/29/2015] [Indexed: 08/31/2023]
Abstract
BACKGROUND General practitioners can safely exclude pulmonary embolism (PE) by using the Wells PE rule combined with D-dimer testing. OBJECTIVE To compare the accuracy of a strategy using the Wells rule combined with either a qualitative point-of-care (POC) D-dimer test performed in primary care or a quantitative laboratory-based D-dimer test. METHODS We used data from a prospective cohort study including 598 adults suspected of PE in primary care in the Netherlands. General practitioners scored the Wells rule and carried out a qualitative POC test. All patients were referred to hospital for reference testing. We obtained quantitative D-dimer test results as performed in hospital laboratories. The primary outcome was the prevalence of venous thromboembolism in low-risk patients. RESULTS Prevalence of PE was 12.2%. POC D-dimer test results were available in 582 patients (97%). Quantitative test results were available in 401 patients (67%). We imputed results in 197 patients. The quantitative test and POC test missed one (0.4%) and four patients (1.5%), respectively, with a negative strategy (Wells ≤ 4 points and D-dimer test negative) (P = 0.20). The POC test could exclude 23 more patients (4%) (P = 0.05). The sensitivity and specificity of the Wells rule combined with a POC test were 94.5% and 51.0% and, combined with a quantitative test, 98.6% and 47.2%, respectively. CONCLUSIONS Combined with the Wells PE rule, both tests are safe to use in excluding PE. The quantitative test seemed to be safer than the POC test, albeit not statistically significant. The specificity of the POC test was higher, resulting in more patients in whom PE could be excluded.
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Affiliation(s)
- W A M Lucassen
- Department of Family Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - P M G Erkens
- Department of Family Medicine, University of Maastricht, Maastricht, the Netherlands
| | - G J Geersing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - H R Büller
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - K G M Moons
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - H E J H Stoffers
- Department of Family Medicine, University of Maastricht, Maastricht, the Netherlands
| | - H C P M van Weert
- Department of Family Medicine, Academic Medical Center, Amsterdam, the Netherlands
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Kline JA, Richardson DM, Than MP, Penaloza A, Roy PM. Systematic review and meta-analysis of pregnant patients investigated for suspected pulmonary embolism in the emergency department. Acad Emerg Med 2014; 21:949-59. [PMID: 25269575 DOI: 10.1111/acem.12471] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Revised: 05/05/2014] [Accepted: 05/09/2014] [Indexed: 01/12/2023]
Abstract
OBJECTIVES Pregnancy causes a small increase in risk of venous thromboembolism (VTE), but a large increase in concern upon presentation to an emergency department (ED) with symptoms of pulmonary embolism (PE), which may cause physicians to employ a low test threshold. This was a systematic review with the hypothesis that symptomatic pregnant patients in the ED have a low relative risk (RR) for VTE outcome. METHODS Studies in all languages were identified by structured search of PubMed, EMBASE, the Cochrane library, and bibliographies in February 2014. Papers with ED patients evaluated for possible PE that included pregnancy status, and had adequate reference standards, were included. An outcome of VTE (either deep venous thrombosis [DVT] or PE) was considered disease-positive (VTE+). Papers were assessed for selection and publication bias, and heterogeneity (I(2) ). The random effects model was used if I(2) > 24%. RESULTS Seventeen full-length studies of 25,339 patients were analyzed. Pooled data showed I² = 0% with a symmetrical funnel plot. Two small studies with less than 1% of all patients had evidence of selection bias. The frequency of VTE+ rate among the 506 pregnant patients was 4.1% (95% confidence interval [CI] = 2.6% to 6.0%), compared with 12.4% (95% CI = 9.0% to 16.3%) among nonpregnant patients. The pooled RR of pregnancy for VTE+ diagnosis was 0.60 (95% CI = 0.41 to 0.87). Patients in the third trimester had a RR of 0.85 (95% CI = 0.40 to 1.77), and patients of childbearing age (≤45 years) had a RR of 0.56 (95% CI = 0.34 to 0.93). CONCLUSIONS In the ED setting, physicians test for PE in pregnant patients at a low threshold, resulting in a low rate of VTE diagnosis and a RR of VTE that is lower than that for nonpregnant women of childbearing age who are tested for PE in the ED setting.
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Affiliation(s)
- Jeffrey A. Kline
- The Department of Emergency Medicine; Indianapolis IN
- The Department of Cellular and Integrative Physiology; Indianapolis IN
- Indiana University School of Medicine; Indianapolis IN
| | | | - Martin P. Than
- The Department of Emergency Medicine; Christchurch Hospital; Christchurch New Zealand
| | - Andrea Penaloza
- The Emergency Department; Cliniques Universitaires St-Luc; Brussels Belgium
| | - Pierre-Marie Roy
- The Department of Emergency Medicine; LUNAM Université; Angers France
- CHU Angers; Université d'Angers; Angers France
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Abstract
Pulmonary embolism (PE) remains one of the most challenging medical diseases in the emergency department. PE is a potentially life threatening diagnosis that is seen in patients with chest pain and/or dyspnea but can span the clinical spectrum of medical presentations. In addition, it does not have any particular clinical feature, laboratory test, or diagnostic modality that can independently and confidently exclude its possibility. This article offers a review of PE in the emergency department. It emphasizes the appropriate determination of pretest probability, the approach to diagnosis and management, and special considerations related to pregnancy and radiation exposure.
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Affiliation(s)
- David W Ouellette
- Department of Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada.
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11
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Fesmire FM, Brown MD, Espinosa JA, Shih RD, Silvers SM, Wolf SJ, Decker WW. Critical issues in the evaluation and management of adult patients presenting to the emergency department with suspected pulmonary embolism. Ann Emerg Med 2011; 57:628-652.e75. [PMID: 21621092 DOI: 10.1016/j.annemergmed.2011.01.020] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
This clinical policy from the American College of Emergency Physicians is the revision of a 2003 clinical policy on the evaluation and management of adult patients presenting with suspected pulmonary embolism (PE).(1) A writing subcommittee reviewed the literature to derive evidence-based recommendations to help clinicians answer the following critical questions: (1) Do objective criteria provide improved risk stratification over gestalt clinical assessment in the evaluation of patients with possible PE? (2) What is the utility of the Pulmonary Embolism Rule-out Criteria (PERC) in the evaluation of patients with suspected PE? (3)What is the role of quantitative D-dimer testing in the exclusion of PE? (4) What is the role of computed tomography pulmonary angiogram of the chest as the sole diagnostic test in the exclusion of PE? (5) What is the role of venous imaging in the evaluation of patients with suspected PE? (6) What are the indications for thrombolytic therapy in patients with PE? Evidence was graded and recommendations were given based on the strength of the available data in the medical literature.
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Lucassen WAM, Douma RA, Toll DB, Büller HR, van Weert HCPM. Excluding pulmonary embolism in primary care using the Wells-rule in combination with a point-of care D-dimer test: a scenario analysis. BMC FAMILY PRACTICE 2010; 11:64. [PMID: 20831834 PMCID: PMC2944151 DOI: 10.1186/1471-2296-11-64] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2010] [Accepted: 09/13/2010] [Indexed: 11/10/2022]
Abstract
BACKGROUND In secondary care the Wells clinical decision rule (CDR) combined with a quantitative D-dimer test can exclude pulmonary embolism (PE) safely. The introduction of point-of-care (POC) D-dimer tests facilitates a similar diagnostic strategy in primary care.We estimated failure-rate and efficiency of a diagnostic strategy using the Wells-CDR combined with a POC-D-dimer test for excluding PE in primary care.We considered ruling out PE safe if the failure rate was <2% with a maximum upper confidence limit of 2.7%. METHODS We performed a scenario-analysis on data of 2701 outpatients suspected of PE. We used test characteristics of two qualitative POC-D-dimer tests, as derived from a meta-analysis and combined these with the Wells-CDR-score. RESULTS In scenario 1 (SimpliRed-D-dimer sensitivity 85%, specificity 74%) PE was excluded safely in 23.8% of patients but only by lowering the cut-off value of the Wells rule to <2. (failure rate: 1.4%, 95% CI 0.6-2.6%)In scenario 2 (Simplify-D-dimer sensitivity 87%, specificity 62%) PE was excluded safely in 12.4% of patients provided that the Wells-cut-off value was set at 0. (failure rate: 0.9%, 95% CI 0.2-2.6%) CONCLUSION Theoretically a diagnostic strategy using the Wells-CDR combined with a qualitative POC-D-dimer test can be used safely to exclude PE in primary care albeit with only moderate efficiency.
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Affiliation(s)
- Wim A M Lucassen
- Department of General Practice, Academic Medical Centre, Amsterdam, The Netherlands.
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D-dimers and efficacy of clinical risk estimation algorithms: sensitivity in evaluation of acute pulmonary embolism. AJR Am J Roentgenol 2009; 193:425-30. [PMID: 19620439 DOI: 10.2214/ajr.08.2186] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The goal of this study was to test the efficacy of clinical risk algorithms and a quantitative immunoturbidimetric D-dimer assay in the evaluation of patients undergoing pulmonary CT angiography for suspected acute pulmonary embolism. SUBJECTS AND METHODS From April 1, 2007, to March 31, 2008, emergency department evaluations for clinically suspected pulmonary embolism were performed with the revised Geneva score, a quantitative D-dimer assay, and pulmonary CT angiography. RESULTS Evaluations for pulmonary embolism were performed for 745 consecutively registered patients, 627 of whom were included in the study. The other 118 patients were excluded because a d-dimer assay was not performed. According to the revised Geneva score, 281 patients had low clinical probability of having pulmonary embolism; 330, intermediate probability; and 16, high probability. CT angiography showed that 28 patients had pulmonary embolism (six in the low-probability group, 17 in the intermediate-probability group, and five in the high-probability group). The sensitivity, negative predictive value, and specificity of the D-dimer assay were 100%, 100%, and 25% (low-clinical-probability group); 100%, 100%, and 33% (intermediate-probability group); and 80%, 80%, and 37% (high-probability group). CONCLUSION The data appear to support the use of a quantitative D-dimer assay as a first-line test in evaluation for pulmonary embolism when the clinical probability of the presence of pulmonary embolism is low or intermediate. The sensitivity and negative predictive value were 100% for these cases. More than 26% of CT angiographic examinations might have been avoided if the D-dimer assay had been used as a first-line test in the care of patients at low or intermediate risk. Because of the small sample size, the D-dimer assay is not recommended as a first-line test in the evaluation of patients at high risk.
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