Diagnosis of acute pulmonary embolism Righini, M.; Robert‐Ebadi, H.; Le Gal, G.
Journal of thrombosis and haemostasis,
July 2017, 2017-Jul, 2017-07-00, 20170701, Letnik:
15, Številka:
7
Journal Article
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Summary
Advances in the management of patients with suspected pulmonary embolism (PE) have improved diagnostic accuracy and made management algorithms safer, easier to use, and well standardized. ...These diagnostic algorithms are mainly based on the assessment of clinical pretest probability, D‐dimer measurement, and imaging tests—predominantly computed tomography pulmonary angiography. These diagnostic algorithms allow safe and cost‐effective diagnosis for most patients with suspected PE. In this review, we summarize signs and symptoms of PE, current existing evidence for PE diagnosis, and focus on the challenge of diagnosing PE in special patient populations, such as pregnant women, or patients with a prior VTE. We also discuss novel imaging tests for PE diagnosis and highlight some of the additional challenges that might require adjustments to current diagnostic strategies, such as the reduced clinical suspicion threshold, resulting in a lower proportion of PE among suspected patients as well as the overdiagnosis of subsegmental PE.
Background: Multiple‐detectors computed tomographic pulmonary angiography (CTPA) has a higher sensitivity for pulmonary embolism (PE) within the subsegmental pulmonary arteries as compared with ...single‐detector CTPA. Multiple‐detectors CTPA might increase the rate of subsegmental PE diagnosis. The clinical significance of subsegmental PE is unknown. We sought to summarize the proportion of subsegmental PE diagnosed with single‐ and multiple‐detectors CTPA and assess the safety of diagnostic strategies based on single‐ or multiple‐detectors CTPA to exclude PE. Patients and methods: A systematic literature search strategy was conducted using MEDLINE, EMBASE and the Cochrane Register of Controlled Trials. We selected 22 articles (20 prospective cohort studies and two randomized controlled trials) that included patients with suspected PE who underwent a CTPA and reported the rate of subsegmental PE. Two reviewers independently extracted data onto standardized forms. Results: The rate of subsegmental PE diagnosis was 4.7% 95% confidence interval (CI): 2.5–7.6 and 9.4 (95% CI: 5.5–14.2) in patients that underwent a single‐ and multiple‐detectors CTPA, respectively. The 3‐month thromboembolic risks in patients with suspected PE and who were left untreated based on a diagnostic algorithm including a negative CTPA was 0.9% (95% CI: 0.4–1.4) and 1.1% (95% CI: 0.7–1.4) for single‐ and multiple‐detectors CTPA, respectively. Conclusion: Multiple‐detectors CTPA seems to increase the proportion of patients diagnosed with subsegmental PE without lowering the 3‐month risk of thromboembolism suggesting that subsegmental PE may not be clinically relevant.
Background: Pretest probability assessment is necessary to identify patients in whom pulmonary embolism (PE) can be safely ruled out by a negative D‐dimer without further investigations. ...Objective: Review and compare the performance of available clinical prediction rules (CPRs) for PE probability assessment. Patients/methods: We identified studies that evaluated a CPR in patients with suspected PE from Embase, Medline and the Cochrane database. We determined the 95% confidence intervals (CIs) of prevalence of PE in the various clinical probability categories of each CPR. Statistical heterogeneity was tested. Results: We identified 9 CPR and included 29 studies representing 31215 patients. Pooled prevalence of PE for three‐level scores (low, intermediate or high clinical probability) was: low, 6% (95% CI, 4–8), intermediate, 23% (95% CI, 18–28) and high, 49% (95% CI, 43–56) for the Wells score; low, 13% (95% CI, 8–19), intermediate, 35% (95% CI, 31–38) and high, 71% (95% CI, 50–89) for the Geneva score; low, 9% (95% CI, 8–11), intermediate, 26% (95% CI, 24–28) and high, 76% (95% CI, 69–82) for the revised Geneva score. Pooled prevalence for two‐level scores (PE likely or PE unlikely) was 8% (95% CI,6–11) and 34% (95% CI,29–40) for the Wells score, and 6% (95% CI, 3–9) and 23% (95% CI, 11–36) for the Charlotte rule. Conclusion: Available CPR for assessing clinical probability of PE show similar accuracy. Existing scores are, however, not equivalent and the choice among various prediction rules and classification schemes (three‐ versus two‐level) must be guided by local prevalence of PE, type of patients considered (outpatients or inpatients) and type of D‐dimer assay applied.
Summary
Over the last decades, important advances have been made in the diagnosis of venous thromboembolism (VTE). Current diagnostic strategies rely on the sequential use of non‐invasive diagnostic ...tests, based on the pretest clinical probability of disease. Diagnostic tests include D‐dimer measurement, leg vein compression ultrasonography, chest computed tomography pulmonary angiography, or ventilation perfusion (V/Q) lung scan. The safety and cost‐effectiveness of these strategies have been extensively validated. They have been widely implemented in clinical practice and have replaced the historical gold standard diagnostic tests (venography and pulmonary angiography). However, new challenges arise, including a lower clinical suspicion threshold and concerns on potential over‐diagnosis of VTE. Moreover, the diagnostic management remains suboptimal in many subgroups of patients with suspected VTE: patients with prior VTE, pregnant women, or elderly patients.
The introduction of computed tomography pulmonary angiography (CTPA) has led to an increase in the incidence of pulmonary embolism (PE) diagnosis. However, the case fatality rate is lower and the ...mortality rates of PE have remained unchanged, suggesting a lower severity of illness. Specifically, the multiple‐detector CTPA increased the rate of subsegmental filling defect reported in patients with suspected PE. Whether these filling defects reported on CTPA would correlate with true subsegmental PE (SSPE) on pulmonary angiography or are actually artifacts is unknown. The inter‐observer agreement for SSPE diagnosis among radiologists with varied levels of experience is low (κ of 0.38; 95% CI, 0.0–0.89). Furthermore, the clinical importance of a symptomatic SSPE diagnosed by CTPA is unclear. SSPE are frequent on pulmonary angiography in patients with a low probability ventilation‐perfusion (V/Q) scan for suspected PE. Several prospective management cohort studies have demonstrated that patients with low or intermediate V/Q scan results can be safely managed without anticoagulation by combining the scan results with the pretest probability (PTP) of PE and compression ultrasonography. Although clinical equipoise exists, the majority of patients diagnosed with SSPE on CTPA are currently treated with anticoagulant therapy. Only a small number of patients with SSPE diagnosed by CTPA and without DVT who did not receive anticoagulation treatment have been reported in the literature. None of these patients suffered recurrent symptomatic VTE (PE or DVT) during the 3‐month follow‐up period (0%; 95% CI, 0–7.4%), suggesting that SSPE might be clinically unimportant. These conclusions are only hypothesis generating and need to be confirmed in prospective clinical management studies before changing clinical practice.
Summary
Background
Post‐thrombotic syndrome (PTS) is the most frequent complication of deep vein thrombosis (DVT). Its diagnosis is based on clinical characteristics. However, symptoms and signs of ...PTS are non‐specific, and could result from concomitant primary venous insufficiency (PVI) rather than DVT. This could bias evaluation of PTS.
Methods
Using data from the REVERSE multicenter study, we assessed risk factors for PTS in patients with a first unprovoked unilateral proximal DVT 5–7 months earlier who were free of clinically significant PVI (defined as absence of moderate or severe venous ectasia in the contralateral leg).
Results
Among the 328 patients considered, the prevalence of PTS was 27.1%. Obesity (odds ratio OR 2.6 95% confidence interval (CI) 1.5–4.7), mild contralateral venous ectasia (OR 2.2 95% CI 1.1–4.3), poor International Normalized Ratio (INR) control (OR per additional 1% of time with INR < 2 during anticoagulant treatment of 1.018 95% CI 1.003–1.034) and the presence of residual venous obstruction on ultrasound (OR 2.1 95% CI 1.1–3.7) significantly increased the risk for PTS in multivariable analyses. When we restricted our analysis to patients without any signs, even mild, of contralateral venous insufficiency (n = 244), the prevalence of PTS decreased slightly to 24.6%. Only obesity remained an independent predictor of PTS (OR 2.6 95% CI 1.3–5.0). Poor INR control and residual venous obstruction also increased the risk, but the results were no longer statistically significant (OR 1.017 95% CI 0.999–1.035 and OR 1.7 95% CI 0.9–3.3, respectively).
Conclusions
After a first unprovoked proximal DVT, obese patients and patients with even mild PVI constitute a group at increased risk of developing PTS for whom particular attention should be paid with respect to PTS prevention. Careful monitoring of anticoagulant treatment may prevent PTS.
Introduction: The incidence of venous thromboembolism (VTE) in patients with multiple myeloma (MM) treated with thalidomide‐ and lenalidomide‐based regimens is high. Recent observational studies have ...suggested that thromboprophylaxis might be efficacious in decreasing the risk of VTE in this population. Purpose: To determine the absolute rates of VTE with and without different thromboprophylactic agents in patients with newly diagnosed or previously treated MM receiving thalidomide‐ or lenalidomide‐based regimens. Results: Patients with newly diagnosed MM treated with thalidomide in combination with dexamethasone have a VTE risk of 4.1 (95% CI, 2.8–5.9) per 100 patient‐cycles. Therapeutic doses of anticoagulants seem to provide the largest absolute risk reduction of VTE. The rate of VTE in patients with previously treated MM receiving thalidomide in combination with dexamethasone is 0.8 (95% CI, 0.1–2.1) per 100 patient‐months. A combination of lenalidomide and dexamethasone is associated with of risk of VTE of 0.8 (95% CI, 0.07–2.0) per 100 patient‐cycles and 0.7 (95% CI, 0.4–0.9) per 100 patient‐cycles in patients with newly diagnosed and previously treated MM, respectively. Similarly, the rates of VTE in patients also receiving thromboprophylaxis with aspirin were 0.9 (95% CI, 0.5–1.5) and 0.6 (95% CI, 0.01–2.1), respectively. Conclusion: Patients with newly diagnosed or previously treated MM receiving thalidomide‐ or lenalidomide‐based regimens in combination with dexamethasone are at high risk of VTE. The benefit of various types of thromboprophylaxis is difficult to quantify in patients with MM receiving immunomodulatory therapy, especially in those receiving lenalidomide‐based therapy or who have previously treated MM. Randomized controlled trials are needed to address this important clinical need.
Thromboprophylaxis for patients with non-surgical isolated lower-limb trauma requiring immobilization is a matter of debate. Our aim was to develop and validate a clinical risk- stratification model ...based on Trauma, Immobilization and Patients' characteristics (the TIP score).
The TIP score criteria and the cut-off were selected by a consensus of international experts (n = 27) using the Delphi method. Retrospective validation was performed in a population-based case-control study (MEGA study). The potential score's impact in anticoagulant treatment was assessed in a prospective single-center observational cohort study.
After four successive rounds, 30 items constituting the TIP score were selected: thirteen items for trauma, three for immobilization and 14 for patient characteristics were selected, each rated on a scale of 1 to 3. In the validation database, the TIP score had an AUC of 0·77 (95% CI 0.70 to 0.85). Using the cut-off proposed by the experts (≥5) and assuming a prevalence of 1·8%, the TIP scores had a sensitivity, specificity and negative predictive values of 89·9%, 30·7% and 99·4% respectively. In the prospective cohort, 84·2% (165/196) of all the patients concerned who presented at the emergency department had a low VTE risk not requiring thromboprophylaxis according to their TIP scores. The 3-month rate of symptomatic VTE was 1/196 95% CI 0.1-2.8 this patient was in the sub-group TIP score ≥5.
For patients with non-surgical lower-limb trauma and orthopedic immobilization, the TIP score allows an individual VTE risk-assessment and shows promising results in guiding thromboprophylaxis.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
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