Lower prevalence of subsegmental pulmonary embolism after application of the YEARS diagnostic algorithm

Abstract

SummaryThe rate of identified isolated subsegmental pulmonary embolism (ssPE) has doubled with advances in computed tomography pulmonary angiography (CTPA) technology, but its clinical relevance is debated. The YEARS diagnostic algorithm was shown to safely reduce the number of required CTPAs in the diagnostic management of PE. We hypothesized that the higher threshold for performing CTPA in YEARS was associated with a lower prevalence of ssPE compared to the conventional diagnostic algorithm. We compared 2291 consecutive patients with suspected PE managed according to YEARS to 3306 consecutive control patients managed according to the Wells score for the prevalence of isolated ssPE. In the YEARS cohort, 52% were managed without CTPA, 12% had pulmonary embolism (PE) of which 10% were isolated ssPE, and the 3‐month diagnostic failure rate was 0·35%. In the control cohort, 32% were managed without CTPA, 20% had PE of which 16% were isolated ssPE, and the 3‐month failure rate was 0·73%. The isolated ssPE prevalence was significantly lower in YEARS (absolute difference 6·2% (95% confidence interval [CI] 1·4–10), Odds Ratio 0·58 (95% CI 0·37–0·90). In conclusion, YEARS is associated with a lower prevalence of isolated ssPE, due to reduction in CTPAs by the higher D‐dimer threshold. This was however not associated with a higher risk of recurrent VTE during follow‐up.

Establishing diagnostic criteria and treatment of subsegmental pulmonary embolism: A Delphi analysis of experts

“…32 Conversely, diagnostic strategies raising the threshold for performing CTPA in the setting of suspected PE are associated with a lower prevalence of ssPE. 33,34 Based on these findings, the latest guidelines of the American College of Chest Physicians have suggested that in patients with ssPEs and no proximal DVT in the legs who have a low risk for recurrent VTE, clinical surveillance is preferred over anticoagulation. 35 Definite evidence for the safety of such an approach has yet to arrive from a prospective single-arm trial (NCT01455818) and a planned randomized controlled trial (NCT04263038).…”

How to manage patients with symptomatic subsegmental pulmonary embolism?

“…Trials such as ADJUST -PE (Age-adjusted D-dimer Cutoff Levels to Rule Out Pulmonary Embolism), YEARS (Simplified diagnostic management of suspected pulmonary embolism), PROPER (Pulmonary Embolism Rule-Out Criteria on Subsequent Thromboembolic Events Among Low-Risk Emergency Department Patients), and PEGeD (Pulmonary Embolism Graduated D-dimer) allow clinicians to significantly decrease the use of diagnostic imaging (ie, CTPA) in patients with a lower C -PTP of having PE. [85][86][87][88] A post hoc analysis of data from 2 prospective studies assessed the prevalence of SSPE in a cohort managed with the YEARS criteria and compared it with the prevalence in a cohort managed with a standard diagnostic strategy. 23,86 The prevalence of SSPE was 10% and 16% in the 2 cohorts, respectively (absolute difference, 6%; 95% CI, 1.4-10).…”

Diagnosis of pulmonary embolism: should we wait YEARS?

“…The clinical significance of these subsegmental PE (ssPE) and the need to treat with anticoagulation is also debatable (Carrier & Klok, 2017). In this month's journal the utility of the YEARS algorithm is further evaluated (van der Pol et al, 2018). In a post-hoc analysis of the original YEARS study, van der Pol et al (2018)compared the number of patients undergoing CTPA (48%) with those in the Christopher study (68%) an earlier prospective PE outcome study performed in the same Dutch hospitals as the YEARS study (van Belle et al, 2006;van der Hulle et al, 2017).…”

“…In this month's journal the utility of the YEARS algorithm is further evaluated (van der Pol et al, 2018). In a post-hoc analysis of the original YEARS study, van der Pol et al (2018)compared the number of patients undergoing CTPA (48%) with those in the Christopher study (68%) an earlier prospective PE outcome study performed in the same Dutch hospitals as the YEARS study (van Belle et al, 2006;van der Hulle et al, 2017). In the YEARS study group PE was identified in 12% (n = 278) of those who underwent imaging, of whom only 28 patients (10% of all PEs diagnosed) were subsegmental.…”

“…The diagnosis of PE is challenging because of the nonspecific symptoms and signs in patients at presentation and the potentially dire consequences of a missed thromboembolic event. For adults presenting with features suggestive of PE, the current guidelines from the United Kingdom National Institute for Health and Care Excellence (NICE 2012), European Society of Cardiology (ESC; Konstantinides et al, 2014) and American College of Chest Physicians (Kearon et al, 2016) all recommend that a pretest probability score is calculated (Wells et al, 2001;Le Gal et al, 2006). In patients with a "likely probability" of PE score, the guidelines recommend proceeding to imaging of the lungs utilising computed tomography pulmonary angiography (CTPA) whereas for those who have an "unlikely probability" of PE measurement of a biomarker in the blood, the D-dimer, is advised.…”