Pulmonary embolism: Accuracy and safety of a negative CT pulmonary angiogram and value of a negative D-dimer assay to exclude CT pulmonary angiogram-detectable pulmonary embolism

2006 ◽  
Vol 50 (5) ◽  
pp. 424-428 ◽  
Author(s):  
RM Subramaniam ◽  
T Chou ◽  
M Swarbrick ◽  
N Karalus
Keyword(s):  
Pulmonary Embolism ◽  
Pulmonary Angiogram ◽  
Ct Pulmonary Angiogram ◽  
D Dimer

Patients with markedly elevated D-dimer who do not have pulmonary embolism

2020 ◽  
pp. postgradmedj-2019-137123
Author(s):  
Jeren Lim ◽  
Calum Cardle ◽  
Chris Isles
Keyword(s):  
Pulmonary Embolism ◽  
Aortic Dissection ◽  
Inclusion Criteria ◽  
Kaplan Meier ◽  
Pulmonary Angiogram ◽  
Ct Pulmonary Angiogram ◽  
Very High ◽  
D Dimer ◽  
Active Cancer

ObjectiveTo determine the cause of a markedly raised D-dimer among patients in whom a diagnosis of pulmonary embolism (PE) has been excluded by CT pulmonary angiogram (CTPA) with particular reference to new cases of cancer and aortic dissection.MethodsOne thousand consecutive patients, suspected of PE, who had undergone CTPA and for whom a D-dimer had been requested, were seen between 2012 and 2016. Retrospectively we examined the case records of all those in the top quintile of the D-dimer distribution whose CTPA was negative for PE. D-dimer in the top quintile ranged from 7.5 to 260 times upper limit normal.ResultsEighty-five patients fulfilled our inclusion criteria. The likely causes of their very high D-dimer were infection (n=35, 41.2%), cardiovascular disease (n=12, 14.1% including two patients with previously undiagnosed aortic dissection), surgery or trauma (n=12, 14.1%), new or active cancer (n=9, 10.6% comprising six new cancers and three patients with cancers diagnosed previously that were considered to be active) and miscellaneous causes (n=17, 20.0%). Thirty-five patients (43.5%) died over a 2-year follow-up. Kaplan-Meier survival analysis showed poorer outcomes for patients with new or active cancer, when compared with those with no known cancer (p<0.001).ConclusionsWe have shown that a small proportion of patients suspected of PE whose D-dimers are markedly elevated have diagnoses we would not want to miss including previously unsuspected cancer and aortic dissection. Further studies will be required to define the optimal workup of patients with extremely high D-dimer who do not have venous thromboembolism

scholarly journals Thrombotic thrombocytopenia following ChAdOx1 nCov-19 vaccination

2021 ◽  
Vol 20 (3) ◽  
pp. 223-226
Author(s):  
A Jafri ◽  
◽  
A Prieto ◽  
Keyword(s):  
Emergency Department ◽  
Pulmonary Embolism ◽  
Medical History ◽  
Thromboembolic Events ◽  
Provisional Diagnosis ◽  
Pulmonary Angiogram ◽  
Ct Pulmonary Angiogram ◽  
Very High ◽  
D Dimer

Serious thromboembolic events with concurrent thrombocytopenia, sometimes accompanied by bleeding, have occurred very rarely following administration of the ChAdOx1 nCoV-19 vaccine. We report the case of a 59-year-old male with an unremarkable medical history who presented to the emergency department with increasing breathlessness five days after receiving the first dose of ChAdOx1 nCov-19. The patient’s blood results showed mild thrombocytopenia and a very high D-dimer, and a pulmonary embolism was confirmed through a CT pulmonary angiogram, which led to a provisional diagnosis of vaccine-induced immune thrombotic thrombocytopenia. The condition was then treated with immunoglobulin and intravenous argatroban in line with the guidance from the Expert Haematology Panel focussed on Vaccine-induced Thrombosis and Thrombocytopenia before conversion to apixaban.

scholarly journals COVID-19 CT pulmonary angiogram examinations and reported pulmonary embolism incidence: comparison between peak first wave and early second wave

2021 ◽  
Vol 76 (4) ◽  
pp. 310-312
Author(s):  
M.T. Tsakok ◽  
Z. Qamhawi ◽  
S.F. Lumley ◽  
C. Xie ◽  
P. Matthews ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Pulmonary Angiogram ◽  
Ct Pulmonary Angiogram ◽  
Second Wave

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

Syncope in pulmonary embolism: a retrospective cohort study

2020 ◽  
pp. postgradmedj-2020-138677
Author(s):  
Craig Richmond ◽  
Hannah Jolly ◽  
Chris Isles
Keyword(s):  
Pulmonary Embolism ◽  
Cohort Study ◽  
Retrospective Cohort Study ◽  
Retrospective Cohort ◽  
District General Hospital ◽  
Clinical Feature ◽  
Pulmonary Angiogram ◽  
Ct Pulmonary Angiogram ◽  
Age Range ◽  
Symptoms And Signs

ObjectiveTo determine the prevalence of syncope or collapse in pulmonary embolism (PE).MethodsA retrospective cohort study was conducted. We examined the frequency with which syncope or collapse (presyncope) occurred alone or with other symptoms and signs in an unselected series of 224 patients presenting to a district general hospital with PE between September 2012 and March 2016. Confirmation of PE was by CT pulmonary angiogram in each case.ResultsOur cohort of 224 patients comprised 97 men and 127 women, average age 66 years with age range of 21–94 years. Syncope or collapse was one of several symptoms and signs that led to a diagnosis of PE in 22 patients (9.8%) but was never the sole presenting feature. In descending order, these other clinical features were hypoxaemia (17 patients), dyspnoea (12), chest pain (9), tachycardia (7) and tachypnoea (7). ECG abnormalities reported to occur more commonly in PE were found in 13/17 patients for whom ECGs were available. Patients with PE presenting with syncope or collapse were judged to have a large clot load in 15/22 (68%) cases.ConclusionSyncope was a frequent presenting symptom in our study of 224 consecutive patients with PE but was never the sole clinical feature. It would be difficult to justify routine testing for PE in patients presenting only with syncope or collapse.

scholarly journals Focus Assessed Transthoracic Echocardiography (FATE) to facilitate the diagnosis of low risk Pulmonary Embolism in Emergency Department

2013 ◽  
Vol 12 (4) ◽  
pp. 459-461 ◽  
Author(s):  
RS Sazwan ◽  
YU Devi ◽  
FM Hashairi ◽  
WAR Wan Faizia
Keyword(s):  
Emergency Department ◽  
Pulmonary Embolism ◽  
Transthoracic Echocardiography ◽  
Gold Standard ◽  
Clinical Presentation ◽  
Medical Science ◽  
Low Risk ◽  
Pulmonary Angiogram ◽  
Ct Pulmonary Angiogram ◽  
Standard Investigation

A diagnosis of Pulmonary Embolism (PE) is difficult that may be missed because of non specific clinical presentation. However, early diagnosis is fundamental, since immediate treatment is highly effective. Thus, with the availability of ultrasound machine in Emergency Department (ED) can help Emergency Physician to diagnose PE by using Focus Assessed Transthoracic Echocardiography (FATE) to facilitate the diagnosis of PE in low risk patient before proceed with the gold standard investigation which is CT Pulmonary Angiogram (CTPA). We believed this case was likely to be repeated on some readers' clinical practice and this procedure is an appropriate option to consider in such cases. DOI: http://dx.doi.org/10.3329/bjms.v12i4.16101 Bangladesh Journal of Medical Science Vol. 12 No. 04 October ’13 Page 459-461

scholarly journals P104: Evaluating the use of the pulmonary embolism rule-out criteria in the emergency department

CJEM ◽  
2018 ◽  
Vol 20 (S1) ◽  
pp. S93-S94
Author(s):  
S. Sharif ◽  
C. Kearon ◽  
M. Eventov ◽  
M. Li ◽  
P. Sneath ◽  
...  
Keyword(s):  
Emergency Department ◽  
Pulmonary Embolism ◽  
False Negative ◽  
False Negative Rate ◽  
Signs And Symptoms ◽  
Ct Scanning ◽  
Pulmonary Angiogram ◽  
Ct Angiogram ◽  
D Dimer ◽  
Rule Out

Introduction: Diagnosing pulmonary embolism (PE) can be challenging because the signs and symptoms are often non-specific. Studies have shown that evidence-based algorithms are not always adhered to in the Emergency Department (ED), which leads to unnecessary CT scanning. The pulmonary embolism rule-out criteria (PERC) can identify patients who can be safely discharged from the ED without further investigation for PE. The purpose of this study is to evaluate the use of the PERC rule in the ED and to compare the rates of testing for PE if the PERC rule was used. Methods: This was a health records review of ED patients investigated for PE at two emergency departments over a two-year period (April 2013-March 2015). Inclusion criteria were ED physician ordered CT pulmonary angiogram, ventilation-perfusion scan, or D-dimer for investigation of PE. Patients under the age of 18 were excluded. PE was considered to be present during the emergency department visit if PE was diagnosed on CT or VQ (subsegmental level or above), or if the patient was subsequently found to have PE or deep vein thrombosis during the next 30 days. Trained researchers extracted anonymized data. The rate of CT/VQ imaging and the negative predictive value was calculated. Results: There were 1,163 patients that were tested for PE and 1,097 patients were eligible for our analysis. Of the total, 330/1,097 (30.1%; 95%CI 27.4-32.3%) had CT/VQ imaging for PE, and 48/1,097 (4.4%; 95%CI 3.3-5.8%) patients were diagnosed with PE. 806/1,097 (73.5%; 95%CI 70.8-76.0%) were PERC positive, and of these, 44 patients had a PE (5.5%; 95%CI 4.1-7.3%). Conversely, 291/1,097 (26.5%; 95%CI 24.0-29.2%) patients were PERC negative, and of these, 4 patients had a PE (1.4%; 95%CI 0.5-3.5%). Of the PERC negative patients, 291/291 (100.0%; 95%CI 98.7-100.0%) had a D-dimer test done, and 33/291 (11.3%; 95%CI 8.2-15.5%) had a CT angiogram. If PERC was used, CT/VQ imaging would have been avoided in 33/1,097 (3%; 95%CI 2.2-4.2%) patients and the D-dimer would have been avoided in 291/1,097 (26.5%; 95%CI 24.0-29.2%) patients. Conclusion: If the PERC rule was used in all patients with suspected PE, fewer patients would have further testing. The false negative rate for the PERC rule was low.

scholarly journals A 10-fold and greater increase in D-dimer at admission in COVID-19 patients is highly predictive of pulmonary embolism in a retrospective cohort study

2021 ◽  
Vol 12 ◽  
pp. 204062072110483
Author(s):  
Adrian Perera ◽  
Pratima Chowdary ◽  
James Johnson ◽  
Lucy Lamb ◽  
Anja Drebes ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
White Cell Count ◽  
Area Under The Curve ◽  
Pulmonary Vasculature ◽  
Reactive Protein ◽  
Pulmonary Angiogram ◽  
Right Ventricular Strain ◽  
Receiver Operator Curve Analysis ◽  
D Dimer ◽  
Operator Curve

Background: COVID-19 patients present with both elevated D-dimer and a higher incidence of pulmonary embolism (PE). This single-centre retrospective observational study investigated the prevalence of early PE in COVID-19 patients and its relation to D-dimer at presentation. Methods: The study included 1038 COVID-19-positive patients, with 1222 emergency department (ED) attendances over 11 weeks (16 March to 31 May 2020). Computed tomography pulmonary angiogram (CTPA) for PE was performed in 123 patients within 48 h of ED presentation, of whom 118 had D-dimer results. The remaining 875 attendances had D-dimer performed. Results: CTPA performed in 11.8% of patients within 48 h of ED presentation confirmed PE in 37.4% (46/123). Thrombosis was observed at all levels of pulmonary vasculature with and without right ventricular strain. In the CTPA cohort, patients with PE had significantly higher D-dimer, prothrombin time, C-reactive protein, troponin, total bilirubin, neutrophils, white cell count and lower albumin compared with non-PE patients. However, there was no difference in the median duration of inpatient stay or mortality. A receiver operator curve analysis demonstrated that D-dimer could discriminate between PE and non-PE COVID-19 patients (area under the curve of 0.79, p < 0.0001). Furthermore, 43% ( n = 62/145) of patients with D-dimer >5000 ng/ml had CTPA with PE confirmed in 61% ( n = 38/62), that is, 26% of >5000 ng/ml cohort. The sensitivity and specificity were related to D-dimer level; cutoffs of 2000, 3000, 4000, and 5000 ng/ml, respectively, had a sensitivity of 93%, 90%, 90% and 86%, and a specificity of 38%, 54%, 59% and 68%, and if implemented, an additional 229, 141, 106 and 83 CTPAs would be required. Conclusion: Our data suggested an increased PE prevalence in COVID-19 patients attending ED with an elevated D-dimer, and patients with levels >5000 ng/ml might benefit from CTPA to exclude concomitant PE.

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