Diagnostic Accuracy of Right Ventricular Dysfunction Markers in Normotensive Emergency Department Patients With Acute Pulmonary Embolism

Weekes, Anthony J.; Thacker, Gregory; Troha, Daniel; Johnson, Angela K.; Chanler-Berat, Jordan; Norton, H. James; Runyon, Michael S.

doi:10.1016/j.annemergmed.2016.01.027

Cited by 52 publications

(35 citation statements)

References 45 publications

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“…Increased right-to-left ventricular ratio correlates with RVD assessed on echocardiography [14–16], all-causes mortality, PE-related mortality, and other composite outcomes [13, 17, 18]. In RDV diagnosed by echocardiography, the sensitivity and specificity of right-to-left ventricular ratio (≥1) measured by CTA are 91% (95% CI 72–99%) and 79% (95% CI 69%-87%), respectively [19]. Furthermore, CTA right-to-left ventricular ratio performs as well as echocardiography ratio to predict death after PE [2, 13, 17, 18, 20] and was used interchangeably as inclusion criteria of intermediate-high risk patients in the large PEITHO study [21].…”

Section: Introductionmentioning

confidence: 99%

Contrast Circulation Time to Assess Right Ventricular Dysfunction in Pulmonary Embolism: A Retrospective Pilot Study

John¹,

Platon

Poletti

et al. 2016

PLoS ONE

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ObjectiveTo optimize enhancement of pulmonary arteries and facilitate diagnosis of pulmonary embolism (PE), modern computed tomography angiography (CTA) contains a contrast bolus tracking system. We explored the diagnostic accuracy of the time-intensity curves given by this automated system to identify right ventricular dysfunction (RVD) in acute PE.Methods114 CTAs with a diagnosis of PE were reviewed. RVD was defined as right-to-left ventricular diameter ratio of 1 or greater. Four parameters on time-intensity curves were identified. Parameters between CTAs with and those without RVD were compared with the Wilcoxon rank-sum test. The ability of the four parameters to discriminate patients with RVD was explored by compiling the area under the operating curves (AUC).ResultsThe time needed by the contrast media to reach the pulmonary artery [8 seconds (IQR: 7–9) versus 7 seconds (IQR: 6–8), p<0.01], the time needed to reach 40 Hounsfield units (HU) [11 seconds (IQR: 8.5–14) versus 9.5 seconds (IQR: 8–10.5), p<0.01], and the contrast intensity reached after 10 seconds [19 HU (IQR: 4–67) versus 53 HU (IQR: 32–80), p<0.05] were all statistically different between CTA with and CTA without RVD. Those three parameters changed gradually across severity categories of RVD (p<0.05 for trend). Their AUC to identify RVD ranged from 0.63 to 0.66. The slope of contrast intensity over time was not informative: [31 HU/s (IQR: 20–57) in CTA with, compared to 36 HU/s (IQR: 22.5–53) in CTA without RVD, p = 0.60].ConclusionSeveral parameters of the time-intensity curve obtained by the bolus tracking system are associated with RVD assessed on CTA images. Of those, the time needed to reach a predefined threshold seems to be the easiest to obtain in any CTA without additional processing time or contrast injection. However, the performance of those parameters is globally low.

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Section: Introductionmentioning

confidence: 99%

Contrast Circulation Time to Assess Right Ventricular Dysfunction in Pulmonary Embolism: A Retrospective Pilot Study

John¹,

Platon

Poletti

et al. 2016

PLoS ONE

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“…The management of massive PE in the ED is of critical importance to lessening mortality burden. Point-of-care FOCUS is a critical tool in assisting with the timely diagnosis of PE [7][8][9][10][11][12]. The case described here again highlights the advantages of using FOCUS to identify signs of RVD in scenarios in which massive PE is clinically suspected, especially given that obtaining a definitive CTPA is challenging in the hemodynamically unstable patient.…”

Section: Discussionmentioning

confidence: 82%

“…Point-ofcare focused cardiac ultrasound (FOCUS) is an invaluable bedside tool to identify signs of right ventricular dysfunction (RVD) that collectively are highly specific for the diagnosis of PE [5,6]. Multiple studies have demonstrated that emergency physicians (EPs) can use FOCUS to accurately detect RVD, including right ventricular dilatation (right ventricular to left ventricular ratio > 1:1), interventricular septal flattening, McConnell's sign (right ventricular mid-basal and mid-apical wall hypokinesis/akinesis with apical hyperkinesis), and tricuspid annular plane systolic excursion (TAPSE) [7][8][9][10][11][12]. There are no studies that have thoroughly investigated implementing serial FOCUS examinations to determine the acute clinical response after systemic thrombolytic therapy for massive PE.…”

Section: Introductionmentioning

confidence: 99%

Serial Point-of-care Echocardiography Performed by an Emergency Physician to Guide Thrombolytic Management of Massive Pulmonary Embolism

Hsu

McClure

et al. 2020

Cureus

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Massive pulmonary embolism (PE) is a life-threatening condition with a high mortality burden. The rapid diagnosis of PE can be supported with focused cardiac ultrasound (FOCUS) by identifying signs of right ventricular dysfunction (RVD). This case report describes a patient with hemodynamically unstable massive PE who received systemic thrombolytic therapy. Emergency physicians performed serial FOCUS examinations to assess the resolution of RVD in guidance of clinical management.

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“…There have been many studies in the literature that delineate the diagnostic test characteristics of the more typical components of the FOCUS examination for PE, , although many of these have not included TAPSE . Our prior work demonstrated the high reliability of EP measured TAPSE in patients with suspected or confirmed PE and suggested a higher testing threshold (2.0 cm vs. 1.7 cm) to increase the examinations sensitivity .…”

Section: Discussionmentioning

confidence: 94%

Increased Sensitivity of Focused Cardiac Ultrasound for Pulmonary Embolism in Emergency Department Patients With Abnormal Vital Signs

Daley

Dwyer

Grunwald

et al. 2019

Academic Emergency Medicine

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Background Focused cardiac ultrasound (FOCUS) is insensitive for pulmonary embolism (PE). Theoretically, when a clot is large enough to cause vital sign abnormalities, it is more likely to show signs of right ventricular dysfunction on FOCUS, although this has not been well quantified. A rapid bedside test that could quickly and reliably exclude PE in patients with abnormal vital signs could be of high utility in emergency department (ED) patients. We hypothesized that in patients with tachycardia or hypotension, the sensitivity of FOCUS for PE would increase substantially. Methods We performed a prospective observational multicenter cohort study involving a convenience sample of patients from six urban academic EDs. Patients suspected to have PE with tachycardia (heart rate [HR] ≥ 100 beats/min) or hypotension (systolic blood pressure [sBP] < 90 mm Hg) underwent FOCUS before computed tomography angiography (CTA). FOCUS included assessment for right ventricular dilation, McConnell's sign, septal flattening, tricuspid regurgitation, and tricuspid annular plane systolic excursion. If any of these were abnormal, FOCUS was considered positive, while if all were normal, FOCUS was considered negative. We a priori planned a subgroup analysis of all patients with a HR ≥ 110 beats/min (regardless of their sBP). We then determined the diagnostic test characteristics of FOCUS for PE in the entire patient population and in the predefined subgroup, based on CTA as the criterion standard. Inter‐rater reliability of FOCUS was determined by blinded review of images by an emergency physician with fellowship training in ultrasound. Results A total of 143 subjects were assessed for enrollment and 136 were enrolled; four were excluded because they were non–English‐speaking and three because of inability to obtain any FOCUS windows. The mean (±SD) age of enrolled subjects was 56 (±7) years, mean (±SD) HR was 114 (±12) beats/min, and 37 (27.2%) subjects were diagnosed with PE on CTA. In all subjects, FOCUS was 92% (95% confidence interval [CI] = 78% to 98%) sensitive and 64% specific (95% CI = 53% to 73%) for PE. In the subgroup of 98 subjects with a HR ≥ 110 beats/min, FOCUS was 100% sensitive (95% CI = 88% to 100%) and 63% specific (95% CI = 51% to 74%) for PE. There was substantial interobserver agreement for FOCUS (κ = 1.0, 95% CI = 0.31 to 1.0). Conclusions A negative FOCUS examination may significantly lower the likelihood of the diagnosis of PE in most patients who are suspected of PE and have abnormal vital signs. This was especially true in those patients with a HR ≥ 110 beats/min. Our results suggest that FOCUS can be an important tool in the initial evaluation of ED patients with suspected PE and abnormal vital signs.

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Diagnostic Accuracy of Right Ventricular Dysfunction Markers in Normotensive Emergency Department Patients With Acute Pulmonary Embolism

Cited by 52 publications

References 45 publications

Contrast Circulation Time to Assess Right Ventricular Dysfunction in Pulmonary Embolism: A Retrospective Pilot Study

Contrast Circulation Time to Assess Right Ventricular Dysfunction in Pulmonary Embolism: A Retrospective Pilot Study

Serial Point-of-care Echocardiography Performed by an Emergency Physician to Guide Thrombolytic Management of Massive Pulmonary Embolism

Increased Sensitivity of Focused Cardiac Ultrasound for Pulmonary Embolism in Emergency Department Patients With Abnormal Vital Signs

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