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.

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.

Is a normal computed tomography pulmonary angiography safe to rule out acute pulmonary embolism in patients with a likely clinical probability?

2017 ◽  
Vol 117 (08) ◽  
pp. 1622-1629 ◽  
Author(s):  
Tom van der Hulle ◽  
Nick van Es ◽  
Paul den Exter ◽  
Josien van Es ◽  
Inge Mos ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Pulmonary Embolism ◽  
Acute Pulmonary Embolism ◽  
Meta Analysis ◽  
Pulmonary Angiography ◽  
Computed Tomography Pulmonary Angiography ◽  
Clinical Probability ◽  
Pulmonary Angiogram ◽  
Wells Rule ◽  
Rule Out

SummaryA normal computed tomography pulmonary angiography (CTPA) remains a controversial criterion for ruling out acute pulmonary embolism (PE) in patients with a likely clinical probability. We set out to determine the risk of VTE and fatal PE after a normal CTPA in this patient category and compare these risk to those after a normal pulmonary angiogram of 1.7% (95%CI 1.0–2.7%) and 0.3% (95%CI 0.02–0.7%). A patient-level meta-analysis from 4 prospective diagnostic management studies that sequentially applied the Wells rule, D-dimer tests and CTPA to consecutive patients with clinically suspected acute PE. The primary outcome was the 3-month VTE incidence after a normal CTPA. A total of 6,148 patients were included with an overall PE prevalence of 24%. The 3-month VTE incidence in all 4,421 patients in whom PE was excluded at baseline was 1.2% (95%CI 0.48–2.6) and the risk of fatal PE was 0.11% (95%CI 0.02–0.70). In patients with a likely clinical probability the 3-month incidences of VTE and fatal PE were 2.0% (95%CI 1.0–4.1%) and 0.48% (95%CI 0.20–1.1%) after a normal CTPA. The 3-month incidence of VTE was 6.3% (95%CI 3.0–12) in patients with a Wells rule >6 points. In conclusion, this study suggests that a normal CTPA may be considered as a valid diagnostic criterion to rule out PE in the majority of patients with a likely clinical probability, although the risk of VTE is higher in subgroups such as patients with a Wells rule >6 points for which a closer follow-up should be considered.Supplementary Material to this article is available online at www.thrombosis-online.com.

scholarly journals P039: Utilization of serum D-dimer assays and computed tomography pulmonary angiography (CTPA) scans in the diagnosis of pulmonary embolism among emergency department (ED) physicians

CJEM ◽  
2020 ◽  
Vol 22 (S1) ◽  
pp. S78-S78
Author(s):  
L. Salehi ◽  
P. Phalpher ◽  
H. Yu ◽  
M. Ossip ◽  
R. Valani ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Pulmonary Embolism ◽  
Decision Rules ◽  
Pulmonary Angiography ◽  
Low Risk ◽  
Urgent Care ◽  
Computed Tomography Pulmonary Angiography ◽  
Risk Patients ◽  
D Dimer ◽  
Rule Out

Introduction: As the availability of Computed Tomography Pulmonary Angiography (CTPA) to rule out pulmonary embolism (PE) increases, so too does its utilization, and consequent overutilization. A variety of evidence-based algorithms and decision rules using clinical criteria and D-Dimer testing have been proposed as instruments to allow physicians to safely rule out a PE in low-risk patients. However, studies have shown mixed results with respect to both physician uptake of these decision rules and their impact on improving ordering practices among physicians. The objective of this study is to describe the prevalence of D-Dimer utilization among ED physicians and its impact on positive yield rates of CTPAs in a community setting. Methods: Data was collected on all CTPA studies ordered by ED physicians at two very high-volume community hospitals and an affiliated urgent care centre during the 2-year period between January 1, 2016 and December 31, 2017. For each CTPA, we determined if 1) a D-Dimer had been ordered prior to CTPA, if 2) the D-Dimer was positive, and if 3) the CTPA was positive for a PE. Using a chi-square test, we compared the diagnostic yield for those patients who had a D-Dimer prior to their CTPA and those who did not. Results: A total of 2,811 CTPAs were included in the analysis. Of these, 964 CTPAs (34.3%) were ordered without a D-Dimer. Of those 1,847 patients who underwent D-Dimer testing prior to the CTPA, 343 (18.7%) underwent a CTPA despite a negative D-Dimer. When compared as a group, those CTPAs preceded by a D-Dimer showed no significant difference in positive yields when compared to those CTPAs ordered without a prior D-Dimer (9.9% versus 11.3%, p = 0.26). Conclusion: The findings of this study present a complicated picture of the impact of D-Dimer utilization on CTPA ordering patterns. There is evidence of suboptimal uptake of routine D-Dimer ordering, and adherence to guidelines in terms of forgoing CTPAs in low-risk patients with negative D-Dimers. While this study design leaves unanswered the question of how many CTPAs were avoided as a result of a negative D-Dimer, the finding of a similar positive yield among those patients who had a D-Dimer ordered versus those who did not is interesting, and illustrative of the issues arising from the high false-positive rates associated with D-Dimer screening.

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.

Sign in / Sign up

Export Citation Format

Share Document