Ten years of imaging for pulmonary embolism: too many scans or the tip of an iceberg?

Morley, Nicholas C. D.; Muir, K.C.; Mirsadraee, Saeed; Beek, Edwin Jacques Rudolph van; Murchison, John T

doi:10.1016/j.crad.2015.07.010

Cited by 12 publications

(9 citation statements)

References 25 publications

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“…[33,37] Morley et al recently published a decade of single institution data finding that imaging-for PE increased 250% (>90% CTPA), PE diagnoses increased 160% and yield reduced from 24 to 20%, but the proportion of large PE was maintained. [40] They suggested that increased imaging in their institution was finding increased rates of previously undiagnosed but clinically significant PE. [40] Our study found no significant correlation for site yield or CTPA utilisation vs. the proportion of large PE.…”

Section: Discussionmentioning

confidence: 99%

“…[40] They suggested that increased imaging in their institution was finding increased rates of previously undiagnosed but clinically significant PE. [40] Our study found no significant correlation for site yield or CTPA utilisation vs. the proportion of large PE. Our data suggests that, within this regions current rates of CTPA utilisation (up to 1.5% of adult ED attenders getting CTPA) and yield, proportions of large PE seem to be maintained at historical levels.…”

Section: Discussionmentioning

confidence: 99%

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RESPECT-ED: Rates of Pulmonary Emboli (PE) and Sub-Segmental PE with Modern Computed Tomographic Pulmonary Angiograms in Emergency Departments: A Multi-Center Observational Study Finds Significant Yield Variation, Uncorrelated with Use or Small PE Rates

et al. 2016

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IntroductionOveruse of CT Pulmonary Angiograms (CTPA) for diagnosing pulmonary embolism (PE), particularly in Emergency Departments (ED), is considered problematic. Marked variations in positive CTPA rates are reported, with American 4–10% yields driving most concerns. Higher resolution CTPA may increase sub-segmental PE (SSPE) diagnoses, which may be up to 40% false positive. Excessive use and false positives could increase harm vs. benefit. These issues have not been systematically examined outside America.AimsTo describe current yield variation and CTPA utilisation in Australasian ED, exploring potential factors correlated with variation.MethodsA retrospective multi-centre review of consecutive ED-ordered CTPA using standard radiology reports. ED CTPA report data were inputted onto preformatted data-sheets. The primary outcome was site level yield, analysed both intra-site and against a nominated 15.3% yield. Factors potentially associated with yield were assessed for correlation.ResultsFourteen radiology departments (15 ED) provided 7077 CTPA data (94% ≥64-slice CT); PE were reported in 1028 (yield 14.6% (95%CI 13.8–15.4%; range 9.3–25.3%; site variation p <0.0001) with four sites significantly below and one above the 15.3% target. Admissions, CTPA usage, PE diagnosis rates and size of PE were uncorrelated with yield. Large PE (≥lobar) were 55% (CI: 52.1–58.2%) and SSPE 8.8% (CI: 7.1–10.5%) of positive scans. CTPA usage (0.2–1.5% adult attendances) was correlated (p<0.006) with PE diagnosis but not SSPE: large PE proportions.Discussion/ ConclusionsWe found significant intra-site CTPA yield variation within Australasia. Yield was not clearly correlated with CTPA usage or increased small PE rates. Both SSPE and large PE rates were similar to higher yield historical cohorts. CTPA use was considerably below USA 2.5–3% rates. Higher CTPA utilisation was positively correlated with PE diagnoses, but without evidence of increased proportions of small PE. This suggests that increased diagnoses seem to be of clinically relevant sized PE.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

RESPECT-ED: Rates of Pulmonary Emboli (PE) and Sub-Segmental PE with Modern Computed Tomographic Pulmonary Angiograms in Emergency Departments: A Multi-Center Observational Study Finds Significant Yield Variation, Uncorrelated with Use or Small PE Rates

et al. 2016

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“…39 With the increasing use of CTPA higher numbers of PE are being diagnosed, including both large and small PE. 23 The number of unsuspected PE being diagnosed on contrast CT of the chest performed for other reasons also supports this hypothesis. 40 There may be out-of-hospital cardiac deaths occurring that are precipitated by the haemodynamic consequences of PE in patients with undiagnosed severe coronary artery disease; however, further studies are required to investigate this.…”

Section: Discussionmentioning

confidence: 64%

Coronary artery calcification is associated with mortality independent of pulmonary embolism severity: a retrospective cohort study

et al. 2019

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To assess coronary artery calcification (CAC) and vascular calcification in patients with pulmonary embolism (PE) and correlate this with mortality. MATERIALS AND METHODS: PE severity was quantified using computed tomography pulmonary angiography (CTPA) in 400 consecutive cases using the modified Miller score (1e5, mild; 6e11, moderate; 12e16, severe). Right ventricle strain was assessed using the right/left ventricle diameter (RV/LV) ratio. CAC score (CACS) was assessed using a four-point scale (CACS mild 1e3, moderate 4e8, severe 9e12) for each vessel and summed to give the total CACS. Follow-up for mortality was obtained at 3 years. RESULTS: PE severity was classified as mild in 48%, moderate in 21%, and severe in 32% of cases. The median modified Miller score was 6 (Interquartile range [IQR] 2, 14) and median total CACS was 2 (IQR 0, 7). All-cause mortality occurred in 128 (32%) patients. Patients with CAC were three times more likely to die than patients without CAC (Hazard ratio [HR] 2.96; 95% CI 1.84, 4.77; p<0.001), and patients with severe CAC were at the highest risk (HR 4.62; 95% CI 2.73, 7.83, p<0.001). Gender, modified Miller score and RV/LV ratio were not predictive of mortality. In multivariate analysis both CACS and age were independent predictors of 3-year all-cause mortality. Of the patients with CAC who died, the presence of coronary artery disease was only documented in 34 (32%). CONCLUSION: CACS is an independent predictor of all-cause mortality in patients with PE, and has important implications for subsequent patient management.

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“…Reported nosebleed improvements were common, though may have also been due to intervening treatment of PAVMs. 2 Conclusions Further study on the clinical efficacy and sequelae of iron treatments, and a more personalised approach to therapy, appears warranted in this patient group. Background Computed tomography of pulmonary angiogram (CTPA) is widely used for the diagnosis of patients with possible pulmonary embolism (PE).…”

mentioning

confidence: 96%

“…1 Furthermore,~1 in 20 HHT patients report that iron treatments exacerbate their nosebleeds. 2 The goal of this study was to evaluate clinical patterns of iron treatments in patients with PAVMs and HHT. Methods Iron, red cell and microbiology indices were evaluated as part of routine clinic assessments of patients with PAVMs and/or HHT.…”

mentioning

confidence: 99%

P180 Managing pregnancy in pulmonary hypertension using a multi-professional approach: a 16-year experience in a specialist referral centre

Klooster

Wilson

Selby

et al. 2017

Pulmonary Vascular Disease: Monitoring and Managing

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BackgroundPulmonary hypertension (PH) in pregnancy is associated with a high risk of maternal death (30%–50%). Despite risks, patients may actively plan pregnancy. Patients may also present whilst pregnant with previously undiagnosed PH.MethodsRetrospective review of patients presenting during pregnancy at a PH centre between 2001 and 2017.ResultsA total of 27 patients were identified over a 16 year period from 2001 till April 2017. Patients were classified as WHO group 1 (n=25) or group 4 (n=2). Eight of the 27 patients had 2 or more pregnancies and in total 36 pregnancies were managed during the study period. Of the 36 pregnancies, 20 resulted in live birth, 9 ended with medical termination and 7 resulted in a miscarriage. All patients were supervised by a multi-professional team (PH physicians, anaesthetists, obstetricians, intensivists and nurse specialists). 19 deliveries were by Caesarean section with 1 vaginal delivery and planned between 32 to 36 weeks; the earliest live birth was at 25+5 weeks post cardiorespiratory arrest at 25 weeks. Patients underwent epidural or combined spinal/epidural regional anaesthesia and were monitored peri-delivery in an intensive care environment with arterial and central venous access. Of 36 pregnancies, 2 women died within 6 months of delivery (3 and 28 days post-delivery) and none during pregnancy. Patients were followed until January 2017; mean follow up 64 months (range 0–174 months) after last pregnancy. The 5 year survival for all patients (n=27) from date of last pregnancy with PH was 92%.ConclusionMortality of PH in pregnancy in a setting of experienced and coordinated care is less than historical series but remains significant. Counselling women with PH of these risks remains an essential part of disease management. In the event of pregnancy, patients should be managed by a multiprofessional team with peripartum care in an intensive care environment.

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Ten years of imaging for pulmonary embolism: too many scans or the tip of an iceberg?

Cited by 12 publications

References 25 publications

RESPECT-ED: Rates of Pulmonary Emboli (PE) and Sub-Segmental PE with Modern Computed Tomographic Pulmonary Angiograms in Emergency Departments: A Multi-Center Observational Study Finds Significant Yield Variation, Uncorrelated with Use or Small PE Rates

RESPECT-ED: Rates of Pulmonary Emboli (PE) and Sub-Segmental PE with Modern Computed Tomographic Pulmonary Angiograms in Emergency Departments: A Multi-Center Observational Study Finds Significant Yield Variation, Uncorrelated with Use or Small PE Rates

Coronary artery calcification is associated with mortality independent of pulmonary embolism severity: a retrospective cohort study

P180 Managing pregnancy in pulmonary hypertension using a multi-professional approach: a 16-year experience in a specialist referral centre

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