Trends in the use of echocardiography in pulmonary embolism

Abstract

Pulmonary embolism (PE) is a devastating diagnosis which carries a high mortality risk. Echocardiography is often performed to risk stratify patients diagnosed with PE, and guide management strategies. Trends in the performance of echocardiography among patients with PE and its role in influencing outcomes is unknown.We analyzed the 2005 to 2014 National Inpatient Sample Database to identify patients with primary diagnosis of PE or secondary diagnosis of PE and ≥1 of the following diagnoses: syncope, thrombolysis, acute deep vein thrombosis, acute cardiorespiratory failure, and secondary pulmonary hypertension. Trends in the performance of echocardiography and in-hospital mortality were analyzed. The admissions were divided into 2 groups with echocardiography, and without echocardiography, and 1:2 propensity score matching (PSM) was performed for comparison. The primary end-point was in-hospital mortality. The secondary endpoints were length of stay and total hospitalization costs. Odd ratios (OR) with confidence intervals (CI) were reported.A total of 299,536 unweighted PE cases were studied. Performance of echocardiography among patients with PE patients increased from 3.5% to 5.6%, whereas in-hospital mortality decreased from 4.2% to 3.7% between years 2005 and 2014. Before matching, patients who received an echocardiogram were more likely to be younger, African American, admitted to a large, urban teaching institute, and had higher rates of concurrent acute deep vein thrombosis, and acute respiratory failure. Post-PSM, patients who received echocardiography during hospitalization had lower in-hospital mortality (odds ratio 0.75, 95% confidence intervals (CI) 0.68-0.83; P < 0.001), longer length of stay (median 6 days vs 5 days; P < .001) and higher mean hospitalization costs ($34,379 vs $27,803; P < .001) compared to those without echocardiography.Performance of echocardiography among patients with a PE is increasing and is associated with lower in-hospital mortality.

Two-dimensional echocardiography after return of spontaneous circulation and its association with in-hospital survival after in-hospital cardiopulmonary resuscitation

“…As rapid 2D echocardiography is required for the diagnosis of possible PAMD during the post-arrest period 13 , patients in our study who did not undergo 2D echocardiography within 24 hours were less likely to receive appropriate treatment for this condition. Second, 2D echocardiography can facilitate the rapid diagnosis or elimination of reversible causes of IHCA 9 , such as acute cardiac tamponade 14 , myocardial infarction 15 , or pulmonary embolism 16 . Therefore, such causes may not have been identified in patients who did not undergo 2D echocardiography (i.e., those in the non-2D echo group), whereas patients in the 2D-echo group were more likely to benefit from rapid detection and treatment.…”

Incremental Value of ePLAR—The Echocardiographic Pulmonary to Left Atrial Ratio in the Assessment of Sub-Massive Pulmonary Emboli

“…Current Guidelines (both European and American) for thrombolysis or catheter-based intervention for PE recommend echocardiographic assessment of RV dysfunction [7,19], and subsequent treatment in the setting of RV dysfunction + hemodynamic instability, with or without CTPA or V/Q scan confirmation of PE [7]. Prognostic advantage has been demonstrated when these criteria lead to lysis/intervention [20]. However, in this study, only 32% had reduced TAPSE while 70% had abnormal ePLAR.…”

“…(C) Normal cases (red) will have normal pulmonary artery pressure (PAP) and left atrial pressure (LAP), normal TRV max (e.g., 2.4 m/s), normal E/e' (e.g., 8), and a predicted ePLAR of approximately 0.30 m/s. Patients with left heart failure (LHF) but with normal pulmonary arterial pressures (PAP mean < 25 mmHg) will have normal TRV max (e.g., 2.4 m/s) with a high E/e' (e.g., 20), yielding an ePLAR of approximately 0.12 m/s (orange). Patients with post-capillary pulmonary hypertension secondary to LHF will have a high TRV max (e.g., 4.0 m/s) and a high E/e' (e.g., 20), yielding an ePLAR of approximately 0.2 m/s (blue).…”

“…Patients with left heart failure (LHF) but with normal pulmonary arterial pressures (PAP mean < 25 mmHg) will have normal TRV max (e.g., 2.4 m/s) with a high E/e' (e.g., 20), yielding an ePLAR of approximately 0.12 m/s (orange). Patients with post-capillary pulmonary hypertension secondary to LHF will have a high TRV max (e.g., 4.0 m/s) and a high E/e' (e.g., 20), yielding an ePLAR of approximately 0.2 m/s (blue). Patients with pre-capillary pulmonary hypertension will have a high TRV max (e.g., 4.0 m/s) with a normal E/e' (e.g., 8), yielding the highest of ePLAR values-approximately 0.50 m/s in this example (green).…”

Cor pulmonale: the role of traditional and advanced echocardiography in the acute and chronic settings

“…In this regard, if a computed tomography pulmonary angiography examination is not immediately available, echocardiography must be performed in these patients, in order first to exclude other conditions that might be responsible for shock and second to demonstrate RV dilatation/dysfunction indicating a pressure overload, with emergency reperfusion therapy being justified solely on these criteria [ 4 ]. Moreover, performing echocardiography in addition to other testing has been associated with a lower in-hospital mortality in APE, likely due to the fact that it speeds up the diagnostic and therapeutic work-up, especially in critical patients [ 5 , 6 ]. Furthermore, a recent meta-analysis confirmed the high specificity and low sensitivity of this technique for diagnosis, which makes it a useful tool to rule-in APE, especially at the bedside [ 7 ].…”