Retrospective Analysis of the Computed Tomography Pulmonary Angiogram Utilization Patterns in the Emergency Department

2019 ◽  
Vol 70 (4) ◽  
pp. 388-393
Author(s):  
Craig Ferguson ◽  
Gavin Low ◽  
Christopher Fung
Keyword(s):  
Computed Tomography ◽  
Pulmonary Embolism ◽  
Clinical Decision Making ◽  
High Rate ◽  
Continuous Variables ◽  
Moderate Risk ◽  
Female Population ◽  
Pulmonary Angiogram ◽  
Utilization Patterns ◽  
D Dimer

Objectives Guidelines and high-quality studies recommend using clinical decision-making (CDM) tools over clinical gestalt when evaluating a patient for pulmonary embolism. The purpose of this study is to investigate our computed tomography pulmonary angiogram (CTPA) utilization patterns and identify causal factors. Methods A retrospective cohort study of CTPA studies ordered by emergency physicians in January, April, July, and October 2017 was undertaken. All necessary information to categorize patients by Wells' score, revised Geneva score, and pulmonary embolism rule-out criteria (PERC) was collected. In addition, various bloodwork, chest radiograph, and computed tomography results were collected. This data was analysed by the Pearson chi-square test or Fisher's exact test for categorical data and independent-samples t test for continuous variables. Results A total of 510 CTPA studies were performed, with a mean age was 61.6 and a 50.6% female population. 136 studies (26.7%) failed to appropriately follow any CDM tool. CDM tool failure rate was dependent on whether the study was ordered from a community (14.9%) or tertiary hospital (University of Alberta Hospital, 27.9% and Royal Alexandra Hospital, 24.6%) ( P = .038). Of these 136 studies, 31 were low/moderate risk and the d-dimer was negative. The remainder were either PERC-negative or low/moderate risk without d-dimer performed. The cumulative positive pulmonary embolism rate was 12.5%. With utilization of a CDM tool, the positive pulmonary embolism rate was 15.0%, compared to 5.9% when using gestalt ( P = .026). Conclusions This study confirms a high rate of CDM tool use failure, and a higher positive CTPA rate for CDM tools compared to clinical gestalt.

Pulmonary Embolism

2019 ◽  
Author(s):  
Nadav Granat ◽  
Evan Avraham Alpert
Keyword(s):  
Computed Tomography ◽  
Pulmonary Embolism ◽  
Blood Clot ◽  
Pretest Probability ◽  
Treatment Modalities ◽  
Pulmonary Vasculature ◽  
Pulmonary Angiogram ◽  
Catheter Directed Thrombolysis ◽  
D Dimer ◽  
Rule Out

Pulmonary embolism is caused by a blood clot that travels from the deep veins through the heart and then lodges in the pulmonary vasculature. Common symptoms include pleuritic chest pain, dyspnea, or palpitations. Clinical scores such as the Wells score and Revised Geneva score can be used to assess the pretest probability of pulmonary embolism (PE) and guide work-up such as deciding to order D-dimer testing or imaging. However, clinical gestalt can also accurately assess the pretest probability of PE. The Pulmonary Embolism Rule-out Criteria is a decision rule that can be used to rule out PE without further testing. Imaging modalities include computed tomography pulmonary angiogram or ventilation/perfusion scanning. Novel or new oral anticoagulants are becoming the mainstay of treatment for the hemodynamically stable patient with pulmonary embolism. For the patient who is hemodynamically unstable, treatment modalities include intravenous alteplase, catheter-directed thrombolysis, surgical embolectomy, and catheter-directed embolectomy. A subset of patients with PE can be treated as outpatients. This review contains 1 figure, 4 tables, and 55 references. Key Words: anticoagulants, antithrombins, D-dimer, low-molecular-weight heparin, mechanical thrombolysis, multidetector computed tomography, radionuclide imaging, unfractionated heparin, pulmonary embolism, tissue plasminogen activator, warfarin

scholarly journals Pulmonary Embolism Detection in COVID-19 Patients

2021 ◽  
Author(s):  
Priyancaa Jeyabaladevan ◽  
Sharenja Jeyabaladevan
Keyword(s):  
Computed Tomography ◽  
Pulmonary Embolism ◽  
Biochemical Marker ◽  
Study Patient ◽  
Single Centre ◽  
Patient Cohort ◽  
Pulmonary Angiogram ◽  
Cutoff Levels ◽  
D Dimer ◽  
Rule Out

Background: A clinically important impact of Coronavirus Disease 2019 (COVID-19) is the increased likelihood of thromboembolism, mainly pulmonary embolism (PE). To screen for these complications a biochemical marker, D-dimer, is usually done. There is a plethora of research validating the use of D-dimer cutoff levels in non-COVID-19 patients, however less so in the COVID-19 population. Aim: To determine the number of suspected COVID patients with D-dimer ≥ 0.5 and PE reported on CTPA. Methods: Non-interventional single-centre retrospective clinical correlational study. Patient cohort was patients admitted with suspected COVID-19 over a 5-week period. N=690. Results: 76.5% of suspected COVID-19 patients were PCR positive. 40% of these patients had a CTPA completed with 19% reported to have a PE. 52% of patients had a D-dimer value ≥ 0.5 10.6% patients had a PE with a D-dimer ≥ 0.5. Conclusion: Nationally, hospitals are adopting existing D-dimer cut off levels to rule out PEs, however this leads to a large proportion of admitted COVID-19 patients having possibly unnecessary computed tomography pulmonary angiogram. This study highlights that majority of patients with D-dimers above the cut off level have negative PEs and contributes to the notion that standard D-dimer cutoffs are insufficiently accurate to be used as a standalone test in diagnosis in the context of an underlying SARS-CoV-2 infection.

scholarly journals Pulmonary Embolism Detection in COVID-19 Patients

2021 ◽  
Vol 4 (3) ◽  
Author(s):  
Priyancaa Jeyabaladevan ◽  
◽  
Sharenja Jeyabaladevan ◽  
Keyword(s):  
Computed Tomography ◽  
Pulmonary Embolism ◽  
Biochemical Marker ◽  
Study Patient ◽  
Single Centre ◽  
Patient Cohort ◽  
Pulmonary Angiogram ◽  
Cutoff Levels ◽  
D Dimer ◽  
Rule Out

Background: A clinically important impact of Coronavirus Disease 2019 (COVID-19) is the increased likelihood of thromboembolism, mainly pulmonary embolism (PE). To screen for these complications a biochemical marker, D-dimer, is usually done. There is a plethora of research validating the use of D-dimer cutoff levels in non-COVID-19 patients, however less so in the COVID-19 population. Aim: To determine the number of suspected COVID patients with D-dimer ≥ 0.5 and PE reported on CTPA. Methods: Non-interventional single-centre retrospective clinical correlational study. Patient cohort was patients admitted with suspected COVID-19 over a 5-week period. N=690. Results: 76.5% of suspected COVID-19 patients were PCR positive. 40% of these patients had a CTPA completed with 19% reported to have a PE. 52% of patients had a D-dimer value ≥ 0.5 10.6% patients had a PE with a D-dimer ≥ 0.5. Conclusion: Nationally, hospitals are adopting existing D-dimer cut off levels to rule out PEs, however this leads to a large proportion of admitted COVID-19 patients having possibly unnecessary computed tomography pulmonary angiogram. This study highlights that majority of patients with D-dimers above the cut off level have negative PEs and contributes to the notion that standard D-dimer cutoffs are insufficiently accurate to be used as a standalone test in diagnosis in the context of an underlying SARS-CoV-2 infection.

Evidence for Age-Adjusted D-Dimer to Rule out Pulmonary Embolism: An Institutional Study

2020 ◽  
Vol 154 (Supplement_1) ◽  
pp. S5-S5
Author(s):  
Ridin Balakrishnan ◽  
Daniel Casa ◽  
Morayma Reyes Gil
Keyword(s):  
Pulmonary Embolism ◽  
False Positive ◽  
False Positive Rate ◽  
Moderate Risk ◽  
Older Population ◽  
Statistical Measures ◽  
Positive Rate ◽  
Risk Patients ◽  
D Dimer ◽  
Rule Out

Abstract The diagnostic approach for ruling out suspected acute pulmonary embolism (PE) in the ED setting includes several tests: ultrasound, plasma d-dimer assays, ventilation-perfusion scans and computed tomography pulmonary angiography (CTPA). Importantly, a pretest probability scoring algorithm is highly recommended to triage high risk cases while also preventing unnecessary testing and harm to low/moderate risk patients. The d-dimer assay (both ELISA and immunoturbidometric) has been shown to be extremely sensitive to rule out PE in conjunction with clinical probability. In particularly, d-dimer testing is recommended for low/moderate risk patients, in whom a negative d-dimer essentially rules out PE sparing these patients from CTPA radiation exposure, longer hospital stay and anticoagulation. However, an unspecific increase in fibrin-degradation related products has been seen with increase in age, resulting in higher false positive rate in the older population. This study analyzed patient visits to the ED of a large academic institution for five years and looked at the relationship between d-dimer values, age and CTPA results to better understand the value of age-adjusted d-dimer cut-offs in ruling out PE in the older population. A total of 7660 ED visits had a CTPA done to rule out PE; out of which 1875 cases had a d-dimer done in conjunction with the CT and 5875 had only CTPA done. Out of the 1875 cases, 1591 had positive d-dimer results (>0.50 µg/ml (FEU)), of which 910 (57%) were from patients older than or equal to fifty years of age. In these older patients, 779 (86%) had a negative CT result. The following were the statistical measures of the d-dimer test before adjusting for age: sensitivity (98%), specificity (12%); negative predictive value (98%) and false positive rate (88%). After adjusting for age in people older than 50 years (d-dimer cut off = age/100), 138 patients eventually turned out to be d-dimer negative and every case but four had a CT result that was also negative for a PE. The four cases included two non-diagnostic results and two with subacute/chronic/subsegmental PE on imaging. None of these four patients were prescribed anticoagulation. The statistical measures of the d-dimer test after adjusting for age showed: sensitivity (96%), specificity (20%); negative predictive value (98%) and a decrease in the false positive rate (80%). Therefore, imaging could have been potentially avoided in 138/779 (18%) of the patients who were part of this older population and had eventual negative or not clinically significant findings on CTPA if age-adjusted d-dimers were used. This data very strongly advocates for the clinical usefulness of an age-adjusted cut-off of d-dimer to rule out PE.

scholarly journals Factors Affecting Radiation Dose in Computed Tomography Angiograms for Pulmonary Embolism: A Retrospective Cohort Study

2020 ◽  
Vol 10 ◽  
pp. 74
Author(s):  
Prashant Nagpal ◽  
Sarv Priya ◽  
Ali Eskandari ◽  
Aidan Mullan ◽  
Tanya Aggarwal ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Pulmonary Embolism ◽  
Radiation Dose ◽  
Care Center ◽  
Tertiary Care ◽  
Multivariate Logistic Regression Analysis ◽  
Factors Affecting ◽  
Model Based ◽  
Pulmonary Angiogram ◽  
The Mean

Objectives: Computed tomography pulmonary angiogram (CTPA) is one of the most commonly ordered and frequently overused tests. The purpose of this study was to evaluate the mean radiation dose to patients getting CTPA and to identify factors that are associated with higher dose. Material and Methods: This institutionally approved retrospective study included all patients who had a CTPA to rule out acute pulmonary embolism between 2016 and 2018 in a tertiary care center. Patient data (age, sex, body mass index [BMI], and patient location), CT scanner type, image reconstruction methodology, and radiation dose parameters (dose-length product [DLP]) were recorded. Effective dose estimates were obtained by multiplying DLP by conversion coefficient (0.014 mSv•mGy−1•cm−1). Multivariate logistic regression analysis was performed to determine the factors affecting the radiation dose. Results: There were 2342 patients (1099 men and 1243 women) with a mean age of 58.1 years (range 0.2–104.4 years) and BMI of 31.3 kg/m2 (range 12–91.5 kg/m2). The mean effective radiation dose was 5.512 mSv (median – 4.27 mSv; range 0.1–43.0 mSv). Patient factors, including BMI >25 kg/m2, male sex, age >18 years, and intensive care unit (ICU) location, were associated with significantly higher dose (P < 0.05). CT scanning using third generation dual-source scanner with model-based iterative reconstruction (IR) had significantly lower dose (mean: 4.90 mSv) versus single-source (64-slice) scanner with filtered back projection (mean: 9.29 mSv, P < 0.001). Conclusion: Patients with high BMI and ICU referrals are associated with high CT radiation dose. They are most likely to benefit by scanning on newer generation scanner using advance model-based IR techniques.

scholarly journals CORRELATION OF D-DIMER LEVEL WITH THE PRESENCE AND SEVERITY OF PULMONARY EMBOLISM ON COMPUTED TOMOGRAPHY PULMONARY ANGIOGRAPHY

2020 ◽  
pp. 33-34
Author(s):  
Mantavya Patel ◽  
Sanjay Paliwal ◽  
Rachit Saxena
Keyword(s):  
Computed Tomography ◽  
Pulmonary Embolism ◽  
Early Diagnosis ◽  
Pulmonary Angiography ◽  
Clinical Suspicion ◽  
Early Prediction ◽  
Computed Tomography Pulmonary Angiography ◽  
Negative Prediction ◽  
D Dimer

Introduction: Early diagnosis of pulmonary embolism can reduce morbidity and motility. D-dimer is well known parameter having high negative prediction value. This study focused on role of D-dimer in early prediction of presence and severity of pulmonary embolism. Material and Methods: Thirty patients with clinical suspicion of pulmonary embolism along with high D-dimer value were included in this study. All selected patients underwent computed tomography pulmonary angiography assessment. D-dimer value was correlated with presence and proximity of pulmonary embolism. Results: Out of thirty selected patients 50% had pulmonary embolism on computed tomography pulmonary angiography assessment. D-dimer value correlated well with presence and proximity of pulmonary embolism. Conclusion: D-dimer value more than 4000 ng/ml had high positive prediction value (79%) in suspected clinical cases. Value more than 8000 ng/ml further improve value to nearly 100% in suspected cases.

Diagnostic management of pulmonary embolism using clinical assessment, plasma D-dimer assay, complete lower limb venous ultrasound and helical computed tomography of pulmonary arteries

2005 ◽  
Vol 93 (05) ◽  
pp. 982-988 ◽  
Author(s):  
Alain Cazanave ◽  
Marie Elias ◽  
Valérie Chabbert ◽  
Henri Juchet ◽  
Hélène Paradis ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Pulmonary Embolism ◽  
Clinical Assessment ◽  
Lower Limb ◽  
Pulmonary Arteries ◽  
Ct Scans ◽  
Helical Computed Tomography ◽  
Diagnostic Strategy ◽  
Clinical Probability ◽  
D Dimer

SummaryThe objective of the study was to assess the clinical validity of a non-invasive diagnostic strategy for acute pulmonary embolism using clinical assessment combined with both ELISA D-dimer and complete lower limb ultrasound (US) examination of proximal and distal veins, before single-detector helical computed tomography (CT) of pulmonary arteries. We expected the strategy to have a high diagnostic exclusion power and to safely decrease the number of CT scans. This prospective, multicenter outcome study included 274 consecutive outpatients. All underwent a priori clinical probability, D-dimer and bilateral complete lower limb US assessments. Only patients with a high clinical probability and both tests negative, or positive D-dimer and negative US assessments, underwent CT. This was deemed necessary in 114 patients (42%). At baseline, venous thromboembolism (VTE) was detected in 110 patients (40%), either by US showing proximal (n=65) or distal (n=36) thrombosis, or by CT (n=9). Anticoagulant was withheld in the remaining patients with negative results in both D-dimer and US but a non-high clinical probability (n=59), or in both US and CT (n=90), or with negative US (n=6) and inadequate CT (n=9). All patients underwent a three-month clinical follow-up. VTE occurred in one patient with inadequate CT, yielding an incidence of 0.6% [95% confidence interval: 0.1–3.4]. No patient died from VTE or had major bleeding. Using clinical probability, ELISA D-dimer and complete US before helical CT is a safe strategy resulting in a substantial reduction in CT scans.

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