Pulmonary embolism: whom to discharge and whom to thrombolyze?

Meyer, Guy; Planquette, Benjamin; Sanchez, Olivier

doi:10.1111/jth.12944

Cited by 18 publications

(6 citation statements)

References 38 publications

(102 reference statements)

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“…The mortality rate in APE differs from >15% in haemodynamically unstable patients, 3-15% in intermediate risk patients with right ventricular dysfunction or myocardial damage and <1% in low risk patients (18). This indicates the importance of distinguishing the relatively small group of haemodynamically unstable high-risk patients from the normotensive intermediate-or low-risk patients (18,19).…”

Section: Apementioning

confidence: 99%

Do radiologists detect chronic thromboembolic disease on computed tomography?

et al. 2019

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Background: Acute pulmonary embolism (APE) is a potentially severe medical condition with blood clots obstructing the pulmonary arterial vasculature. In most cases the APE resolves without any sequelae after anticoagulation therapy. In some patients, however, the emboli do not resolve upon treatment and the remnants cause increased vascular resistance, a condition known as chronic thromboembolic pulmonary hypertension (CTEPH). Both APE and CTEPH have a non-specific clinical presentation and imaging is an important part of the diagnosis. In APE computed tomography pulmonary angiography (CTPA) is the diagnostic gold standard, although the method is not suitable for all patients. CTPA has a high specificity for CTEPH, but the sensitivity remains under debate. At present CTPA is not recommended as a first line test among patients with a clinical suspicion of CTEPH. Purpose: To investigate unestablished imaging modalities in the diagnosis of APE (Study I) and CTEPH (Study III) including learning aspects (Study II) and knowledge (Study IV) of theses among radiologists. Regarding APE we studied magnetic resonance imaging (MRI) and in CTEPH we studied CTPA. Material and methods: Studies I-II were based on a prospective collection of 70 unenhanced MRI exams with CTPA as the gold standard. In Studies III-IV we used a retrospective material based on 43 CTPA exams from patients with confirmed CTEPH referred for presurgical assessment at a specialist centre, with a matched control with suspected APE. Results: All MRI exams were of diagnostic quality. Specificity was 100% for both readers and sensitivity 90% and 93% respectively with a nearly perfect inter-reader agreement (kappa 0.97) (Study I). Residents interpreting the MRI exams within the training program reached a clinically acceptable level after approximately 50 examinations and review time was halved during the training program (Study II). The sensitivity for CTEPH on CTPA reviewed by two experts was 100% and the specificity 100% (Study III), while the sensitivity based on the original reports from the same cases was 26% (Study IV). Conclusions: Unenhanced MRI has a high sensitivity and specificity for APE (Study I) and residents can learn to interpret such exams by using a self-directed training program (Study II). Enhanced CTPA has a high sensitivity when reviewed by experienced radiologists (Study III), but among radiologists in general the sensitivity is low (Study IV). LIST OF SCIENTIFIC PAPERS I. Detection of pulmonary embolism using repeated MRI acquisitions without respiratory gating: A preliminary study.

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Section: Apementioning

confidence: 99%

Do radiologists detect chronic thromboembolic disease on computed tomography?

et al. 2019

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“…The concept of risk-adjusted management was confirmed by randomised trials such as the pulmonary embolism thrombolysis (PEI-THO) and the outpatient treatment of pulmonary embolism (OTPE) trials and management studies such as the Hestia study [7][8][9]. Evidence is accumulating that home treatment or early discharge is a valuable treatment option for selected patients with low-risk PE [10][11][12]. Thus, current guidelines emphasise the importance of risk stratification to guide riskadjusted therapeutic decision-making [1,13].…”

Section: Introductionmentioning

confidence: 99%

Temporal trends in management and outcome of pulmonary embolism: a single-centre experience

et al. 2019

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Background Real-world data on the impact of advances in risk-adjusted management on the outcome of patients with pulmonary embolism (PE) are limited. Methods To investigate temporal trends in treatment, in-hospital adverse outcomes and 1-year mortality, we analysed data from 605 patients [median age, 70 years (IQR 56-77) years, 53% female] consecutively enrolled in a single-centre registry between 09/2008 and 08/2016. Results Over the 8-year period, more patients were classified to lower risk classes according to the European Society of Cardiology (ESC) 2014 guideline algorithm while the number of high-risk patients with out-of-hospital cardiac arrest (OHCA) increased. Although patients with OHCA had an exceptionally high in-hospital mortality rate of 59.3%, the rate of PE-related in-hospital adverse outcomes (12.2%) in the overall patient cohort remained stable over time. The rate of reperfusion treatment was 9.6% and tended to increase in high-risk patients. We observed a decrease in the median duration of in-hospital stay from 10 (IQR 6-14) to 7 (IQR 4-15) days, an increase of patients discharged early from 2.1 to 12.2% and an increase in the use of non-vitamin K-dependent oral anticoagulants (NOACs) from 12.6 to 57.2% in the last 2 years (09/2014-08/2016) compared to first 6 years (09/2008-08/2014). The 1-year mortality rate (16.9%) remained stable throughout the study period. Conclusion In-hospital adverse outcomes and 1-year mortality remained stable despite more patients with OHCA, shorter in-hospital stays, more patients discharged early and a more frequent NOAC use.

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“…Acute pulmonary embolism (APE) is a common cause of hospital and mortality, which results in a heavy disease burden on both families and countries [ 1 ]. The clinical severity of APE is variable and ranges from minor symptoms to right ventricular dysfunction and cardiogenic shock [ 2 , 3 ]. The early detection of high-risk patients represents an important step in prudent therapeutic decision making and reducing the risk of mortality.…”

Section: Introductionmentioning

confidence: 99%

Additive prognostic value of serum calcium to the ESC risk stratification in patients with acute pulmonary embolism

et al. 2023

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Background Hypocalcemia has been shown to be involved in the adverse outcomes of acute pulmonary embolism (APE). We aimed to determine the incremental value of adding hypocalcemia, defined as serum calcium level ≤ 2.12 mmol/L, on top of the European Society of Cardiology (ESC) prognostic algorithm, for the prediction of in-hospital mortality in APE patients, which in turn could lead to the optimization of APE management. Methods This study was conducted at West China Hospital of Sichuan University from January 2016 to December 2019. Patients with APE were retrospectively analyzed and divided into 2 groups based on serum calcium levels. Associations between hypocalcemia and adverse outcomes were assessed by Cox analysis. The accuracy of risk stratification for in-hospital mortality was assessed with the addition of serum calcium to the current ESC prognostic algorithm. Results Among 803 patients diagnosed with APE, 338 (42.1%) patients had serum calcium levels ≤ 2.12 mmol/L. Hypocalcemia was significantly associated with higher in-hospital and 2-year all-cause mortality compared to the control group. The addition of serum calcium to ESC risk stratification enhanced net reclassification improvement. Low-risk group with serum calcium level > 2.12 mmol/L had a 0% mortality rate, improving the negative predictive value up to 100%, while high-risk group with serum calcium level ≤ 2.12 mmol/L indicated a higher mortality of 25%. Conclusion Our study identified serum calcium as a novel predictor of mortality in patients with APE. In the future, serum calcium may be added to the commonly used ESC prognostic algorithm for better risk stratification of patients suffering from APE.

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Pulmonary embolism: whom to discharge and whom to thrombolyze?

Cited by 18 publications

References 38 publications

Do radiologists detect chronic thromboembolic disease on computed tomography?

Do radiologists detect chronic thromboembolic disease on computed tomography?

Temporal trends in management and outcome of pulmonary embolism: a single-centre experience

Additive prognostic value of serum calcium to the ESC risk stratification in patients with acute pulmonary embolism

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