Pregnancy-Adapted YEARS Algorithm for Diagnosis of Suspected Pulmonary Embolism

Pol, Liselotte M. van der; Tromeur, Cécile; Bistervels, Ingrid M.; Áinle, Fionnuala Ní; Bemmel, Thomas van; Bertoletti, Laurent; Couturaud, Francis; Dooren, Yordi P.A. van; Elias, Antoine; Faber, Laura M.; Hofstee, H.M.A.; Hulle, Tom van der; Kruip, Marieke J.H.A.; Maignan, Maxime; Mairuhu, Albert T.A.; Middeldorp, Saskia; Nijkeuter, Mathilde; Roy, Pierre‐Marie; Sanchez, Olivier; Schmidt, Jeannot; Wolde, Marije ten; Klok, Frederikus A.; Huisman, Menno V.

doi:10.1056/nejmoa1813865

Cited by 208 publications

(171 citation statements)

References 35 publications

Supporting

Mentioning

164

Contrasting

Unclassified

Order By: Relevance

“…Overall, PE was diagnosed in 7% of patients, which is in agreement with previously reported data [20][21][22][23][24]. This rate of PE-positive CTPAs is about half the rate usually reported in the general non-pregnant population, confirming the challenging nature of clinical assessment for PE during pregnancy [25, (Table 2) was found to predict PE presence on CTPA.…”

Section: Discussionsupporting

confidence: 89%

“…Finally, our low rate of PE (7%) may have prevented us from detecting significant differences between our two groups. However, our PE prevalence was nearly three times higher than previously described in pregnant women [37], and nearly double compared with data published by van der Pol et al [22]. Only Righini et al [23] reported a similar prevalence of PE (7.1%).…”

Section: Discussionsupporting

confidence: 64%

“…Righini et al [23] used a conservative threshold of 500 μg/L. Van der Pol et al [22] used 1000 μg/L for patients not meeting any YEARS criteria (clinical signs of DVT, hemoptysis, and PE being the most likely diagnosis), or 500 μg/L in the presence of one or more YEARS criteria. Our results showed equal elevation of D-dimer levels in women with and without PE, and D-dimer levels of < 1000 μg/L in one third of our patients with PE.…”

Section: Discussionmentioning

confidence: 99%

“…Our results showed equal elevation of D-dimer levels in women with and without PE, and D-dimer levels of < 1000 μg/L in one third of our patients with PE. These findings raise questions regarding the reliability of higher PE-specific D-dimer thresholds, as proposed by some authors [22]. In many hospitals worldwide and in our hospital, CTPA has become the first-line modality to exclude acute PE in pregnant women, despite the current guidelines advocating V/Q scanning, when available [27].…”

Section: Discussionmentioning

confidence: 99%

“…Recently proposed management algorithms for acute PE suspicion in pregnant women do no longer include chest Xrays and focus on structuring the clinical and paraclinical workup to appropriately select patients who will likely benefit from CTPA [22,23]. At our hospital, chest X-rays were avoided in most patients (93%) to reduce radiation exposure, based on the limited role of X-rays to drive management strategies in pregnant women [9].…”

Section: Discussionmentioning

confidence: 99%

See 4 more Smart Citations

Pulmonary embolism during pregnancy: a 17-year single-center retrospective MDCT pulmonary angiography study

et al. 2019

View full text Add to dashboard Cite

Objectives To determine the prevalence of pulmonary embolism (PE) and alternative diagnoses detected by computed tomography pulmonary angiography (CTPA) in pregnant women; and to assess changes over time regarding radiation dose, technical quality, and examination frequency. Materials and methods This retrospective study included all pregnant women referred for CTPA due to clinically suspected PE over 17 years. Two blinded radiologists reviewed the CTPAs in consensus with regard to PE, alternative diagnoses, and technical quality. We retrieved patient data regarding radiation dose metrics and associated clinical and laboratory parameters. Subgroup comparisons were performed (Wilcoxon and Kruskal-Wallis tests). Results Of the 237 identified patients, 8 (3.3%) were excluded due to inadequate technical CTPA quality, and 229 patients were analyzed (mean age, 31.7 years; mean gestational age, 28 ± 7 weeks). The four different CT systems used over the study period had similar technical quality (p = 0.28). Of 229 patients 16 (7%) patients had PE, 144 (62.9%) had no abnormal findings, and 69 (30.1%) had an alternative diagnosis (consolidation, other pulmonary opacities, pleural effusion, and basal atelectasis). Gestational age, symptoms, and D-dimer levels were not significantly different between patients with or without PE (p > 0.05). Over time, radiation dose exposure decreased by 30% (p < 0.001), while the number of annual examinations increased by > 4-folds. Conclusions In pregnant women, CTPA rarely indicates PE and more often shows alternative diagnoses. Over 17 years, the use of CTPA in pregnancy has notably increased, while the radiation dose exposure has decreased by one third. Key Points • The use of CTPA in pregnancy has steadily risen over the last 17 years • In pregnant women, CTPA rarely reveals PE and more often shows alternative diagnoses • Recent technical improvements have substantially decreased the radiation dose exposure inherent in CTPA without reducing diagnostic image quality

show abstract

Section: Discussionsupporting

confidence: 89%

Section: Discussionsupporting

confidence: 64%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

See 3 more Smart Citations

Pulmonary embolism during pregnancy: a 17-year single-center retrospective MDCT pulmonary angiography study

et al. 2019

View full text Add to dashboard Cite

show abstract

Pulmonary Embolism Prevalence Among Hospitalized Patients With COPD—Reply

Couturaud

Sanchez

Bertoletti

2021

JAMA

Self Cite

View full text Add to dashboard Cite

Acute Pulmonary Embolism

Freund

Cohen‐Aubart

Bloom

2022

JAMA

View full text Add to dashboard Cite

ImportancePulmonary embolism (PE) is characterized by occlusion of blood flow in a pulmonary artery, typically due to a thrombus that travels from a vein in a lower limb. The incidence of PE is approximately 60 to 120 per 100 000 people per year. Approximately 60 000 to 100 000 patients die from PE each year in the US.ObservationsPE should be considered in patients presenting with acute chest pain, shortness of breath, or syncope. The diagnosis is determined by chest imaging. In patients with a systolic blood pressure of at least 90 mm Hg, the following 3 steps can be used to evaluate a patient with possible PE: assessment of the clinical probability of PE, D-dimer testing if indicated, and chest imaging if indicated. The clinical probability of PE can be assessed using a structured score or using clinical gestalt. In patients with a probability of PE that is less than 15%, the presence of 8 clinical characteristics (age &lt;50 years, heart rate &lt;100/min, an oxygen saturation level of &gt; 94%, no recent surgery or trauma, no prior venous thromboembolism event, no hemoptysis, no unilateral leg swelling, and no estrogen use) identifies patients at very low risk of PE in whom no further testing is needed. In patients with low or intermediate clinical probability, a D-dimer level of less than 500 ng/mL is associated with a posttest probability of PE less than 1.85%. In these patients, PE can be excluded without chest imaging. A further refinement of D-dimer threshold is possible in patients aged 50 years and older, and in patients with a low likelihood of PE. Patients with a high probability of PE (ie, &gt;40% probability) should undergo chest imaging, and D-dimer testing is not necessary. In patients with PE and a systolic blood pressure of 90 mm Hg or higher, compared with heparin combined with a vitamin K antagonist such as warfarin followed by warfarin alone, direct oral anticoagulants such as apixaban, edoxaban, rivaroxaban, or dabigatran, are noninferior for treating PE and have a 0.6% lower rate of bleeding. In patients with PE and systolic blood pressure lower than 90 mm Hg, systemic thrombolysis is recommended and is associated with an 1.6% absolute reduction of mortality (from 3.9% to 2.3%).Conclusions and RelevanceIn the US, PE affects approximately 370 000 patients per year and may cause approximately 60 000 to 100 000 deaths per year. First-line therapy consists of direct oral anticoagulants such as apixaban, edoxaban, rivaroxaban, or dabigatran, with thrombolysis reserved for patients with systolic blood pressure lower than 90 mm Hg.

show abstract

Pregnancy-Adapted YEARS Algorithm for Diagnosis of Suspected Pulmonary Embolism

Cited by 208 publications

References 35 publications

Pulmonary embolism during pregnancy: a 17-year single-center retrospective MDCT pulmonary angiography study

Pulmonary embolism during pregnancy: a 17-year single-center retrospective MDCT pulmonary angiography study

Pulmonary Embolism Prevalence Among Hospitalized Patients With COPD—Reply

Acute Pulmonary Embolism

Contact Info

Product

Resources

About