Assessment of Right Ventricular Strain by Computed Tomography Versus Echocardiography in Acute Pulmonary Embolism

Dudzinski, David M.; Hariharan, Praveen; Parry, Blair A.; Chang, Yuchiao; Kabrhel, Christopher

doi:10.1111/acem.13108

Cited by 52 publications

(26 citation statements)

References 24 publications

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“…The consensus of the international guidelines and more recent studies shows that signs of right heart dysfunction on CTPA are a negative prognostic indicator. Markers of increased pulmonary pressure such as RV dilatation, septal bowing or an increased RV/left ventricular (LV) ratio are findings that would warrant admission and commencement of anticoagulation therapy but there are some limitations in RV assessment . The benefit of RV assessment on CTPA is that most patients will undergo this investigation as part of their routine diagnostic work‐up and calculation of a RV/LV ratio to >0.9 and >1.0 (respectively) has been shown to predict accurately in‐hospital death and clinical deterioration in haemodynamically stable patients .…”

Section: Predicting Prognosis and Stratification For Managementmentioning

confidence: 99%

“…The benefit of RV assessment on CTPA is that most patients will undergo this investigation as part of their routine diagnostic work‐up and calculation of a RV/LV ratio to >0.9 and >1.0 (respectively) has been shown to predict accurately in‐hospital death and clinical deterioration in haemodynamically stable patients . While CTPA has a high negative and positive predictive value in patients with an intermediate or high pre‐test probability, it is limited in its dynamic cardiac assessment unless a gated study is performed . Furthermore, there is contradictory evidence that RV dilatation, one of the common parameters, is not significant in prognostic prediction .…”

Section: Predicting Prognosis and Stratification For Managementmentioning

confidence: 99%

“…Markers of increased pulmonary pressure such as RV dilatation, septal bowing or an increased RV/left ventricular (LV) ratio are findings that would warrant admission and commencement of anticoagulation therapy but there are some limitations in RV assessment. 5,[16][17][18]29,30 The benefit of RV assessment on CTPA is that most patients will undergo this investigation as part of their routine diagnostic work-up and calculation of a RV/LV ratio to >0.9 and >1.0 (respectively) has been shown to predict accurately in-hospital death and clinical deterioration in haemodynamically stable patients. 50,57 While CTPA has a high negative and positive predictive value in patients with an intermediate or high pre-test probability, it is limited in its dynamic cardiac assessment unless a gated study is performed.…”

Section: Right Heart Strain On Ctmentioning

confidence: 99%

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Acute pulmonary embolism: a concise review of diagnosis and management

Hepburn-Brown

Darvall

Hammerschlag

2019

Internal Medicine Journal

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An acute pulmonary embolism (aPE) is characterised by occlusion of one or more pulmonary arteries. Physiological disturbance may be minimal, but often cardiac output decreases as the right ventricle attempts to overcome increased afterload. Additionally, ventilation‐perfusion mismatches can develop in affected vascular beds, reducing systemic oxygenation. Incidence is reported at 50–75 per 100 000 in Australia and New Zealand, with 30‐day mortality rates ranging from 0.5% to over 20%. Incidence is likely to increase with the ageing population, increased survival of patients with comorbidities that are considered risk factors and improving sensitivity of imaging techniques. Use of clinical prediction scores, such as the Wells score, has assisted in clinical decision‐making and decreased unnecessary radiological investigations. However, imaging (i.e. computed tomography pulmonary angiography or ventilation‐perfusion scans) is still necessary for objective diagnosis. Anti‐coagulation remains the foundation of PE management. Haemodynamically unstable patients require thrombolysis unless absolutely contraindicated, while stable patients with right ventricular dysfunction or ischaemia should be aggressively anti‐coagulated. Stable patients with no right ventricular dysfunction can be discharged home early with anti‐coagulation and review. However, treatment should be case dependent with full consideration of the patient’s clinical state. Direct oral anti‐coagulants have become an alternative to vitamin K antagonists and are facilitating shorter hospital admissions. Additionally, duration of anti‐coagulation must be decided by considering any provoking factors, bleeding risk and comorbid state. Patients with truly unprovoked or idiopathic PE often require indefinite treatment, while in provoked cases it is typically 3 months with some patients requiring longer periods of 6–12 months.

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Section: Predicting Prognosis and Stratification For Managementmentioning

confidence: 99%

Section: Predicting Prognosis and Stratification For Managementmentioning

confidence: 99%

Section: Right Heart Strain On Ctmentioning

confidence: 99%

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Acute pulmonary embolism: a concise review of diagnosis and management

Hepburn-Brown

Darvall

Hammerschlag

2019

Internal Medicine Journal

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“…Our study indicates that even the small number of “rarely appropriate” TTEs performed in the CICU may in fact play an important role in the assessment of critically ill patients, and that AUC may need to be specifically targeted to the CICU to reflect inability to obtain certain diagnostic tests of choice. For example, though computed tomographic angiography (CTA) is considered a superior modality compared to TTE for diagnosis of pulmonary embolism (PE), CICU patients with suspected PE may have a tenuous clinical status that precludes travel to the CTA scanner (as occurred in 6 patients in our study population). In a CICU population, TTE may be a reasonable alternative diagnostic approach to identify structural and functional abnormalities that indicate PE.…”

Section: Discussionmentioning

confidence: 99%

The application of appropriate use criteria for transthoracic echocardiography in a cardiac intensive care unit

et al. 2019

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Background Appropriate use criteria (AUC) represent an important mechanism by which to promote the rational utilization of healthcare resources. No study to date has been conducted assessing the applicability of current AUC to transthoracic echocardiograms (TTEs) performed in a cardiac intensive care unit (CICU). We analyzed 2 years of consecutive TTEs performed in a CICU at a quaternary‐care academic medical center, hypothesizing that current AUC may not adequately describe the role of TTE in a modern CICU. Methods Indications for TTEs were independently classified by two investigators in accordance with 2011 AUC. If investigators were unable to assign an AUC classification to a given study, it was deemed to be unclassifiable. Disagreements between investigators were resolved by consensus. Cases in which consensus could not be reached underwent definitive adjudication by a third investigator. Results Of the 826 TTEs, 619 TTEs were classified as appropriate (74.9%, CI 71.8%–77.9%), 12 as uncertain (1.5%, CI 0.75%–2.5%), 21 as rarely appropriate (2.5%, CI 1.6%–3.9%), and 174 were unable to be classified (21.1%, CI 18.3%–24.0%). The most common unclassifiable indication was “initial evaluation of cardiac structure or function after cardiac arrest of unknown etiology” (n = 101). Conclusion Current AUC for TTEs may not adequately address the complexity of clinical cases encountered in the CICU. In our study of 826 consecutive TTEs, 21.1% were unable to be classified, reflecting the difficulty in applying AUC to this unique clinical environment. Further studies are therefore needed to better delineate the appropriateness of TTEs performed in the CICU.

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“…58 The detection and calculation of this ratio has recently been automated requiring no human operator input 59 and is becoming increasingly part of the prognostic information used for triaging patients with potential for deterioration, though its lack of specificity requires additional studies such as echocardiography for critical decision making. 60 …”

Section: Ct Angiography For Diagnosis and Prognosticationmentioning

confidence: 99%

Diagnosis of Deep Venous Thrombosis and Pulmonary Embolism

Rahaghi

Minhas

Heresi

2018

Clinics in Chest Medicine

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Imaging continues to be the modality of choice for the diagnosis of venous thromboembolic disease, particularly when incorporated into diagnostic algorithms. Improvement in imaging techniques as well as new imaging modalities and processing methods have improved diagnostic accuracy and additionally are being leveraged in prognostication and decision making for choice of intervention. In this article, we review the role of imaging in diagnosis and prognostication of venous thromboembolism. We also discuss emerging imaging approaches that may in the near future find clinical usefulness in improving diagnosis and prognostication as well as differentiating disease phenotypes.

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Assessment of Right Ventricular Strain by Computed Tomography Versus Echocardiography in Acute Pulmonary Embolism

Abstract: In acute PE, CT is highly sensitive but only moderately specific for RVS compared to TTE. RVS on both CT and TTE predicts more events than either modality alone. TTE confers additional positive prognostic value compared to CT in predicting post-PE clinical deterioration.

Cited by 52 publications

References 24 publications

Acute pulmonary embolism: a concise review of diagnosis and management

Acute pulmonary embolism: a concise review of diagnosis and management

The application of appropriate use criteria for transthoracic echocardiography in a cardiac intensive care unit

Diagnosis of Deep Venous Thrombosis and Pulmonary Embolism

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