The diagnostic management of suspected pulmonary embolism

Pulmonary embolism is a potentially fatal disease in which early recognition and institution of anticoagulant treatment can prevent mortality. The diagnostic tools available to establish whether a patient has a pulmonary embolism were limited to pulmonary angiography and ventilation-perfusion scintigraphy. Both tests have considerable limitations. Helical CT evolved as a new technique in diagnosing PE and gained widespread interest but has been implemented rapidly, without appropriate assessment in clinical practice. The Christopher-study was performed to investigate whether a dichotomization of the Wells clinical decision rule, classifying patients into __PE unlikely__ and __PE likely__ in combination with a D-dimer test is safe to rule out pulmonary embolism in patients with a clinical suspicion. Furthermore, the study was designed to investigate whether helical CT is safe to rule out PE without performing any additional diagnostic tests. In patients in whom PE was excluded by a clinical decision rule indicating __PE unlikely__ combined with a negative D-dimer, during three months of follow-up venous thrombo-embolism was diagnosed in 5 out of 1028 untreated patients (0.5%, 95%CI: 0.2-1.1). In patients in whom CT had ruled out PE, during three months follow-up 18 of 1446 untreated patients experienced a venous thrombo-embolic event (1.3%, 95%CI: 0.7-2.0). In conclusion, the Christopher-study demonstrates that a simple diagnostic algorithm consisting of a dichotomised clinical decision rule, D-dimer and helical CT can guide treatment decisions with a low risk of subsequent venous thrombo-embolism.Roche Diagnostics, Glaxo Smith Kline, Actelion, Astra ZenecaUBL - phd migration 201

Current practice patterns of outpatient management of acute pulmonary embolism: A post-hoc analysis of the YEARS study

Background: Studies have shown the safety of home treatment of patients with pulmonary embolism (PE) at low risk of adverse events. Management studi

Local Ultrasound-Facilitated Thrombolysis in High-Risk Pulmonary Embolism: First Dutch Experience

Purpose To provide insight into the current use and results of ultrasound-facilitated catheter-directed thrombolysis (USAT) in patients with high-risk pulmonary embolism (PE). Introduction Systemic thrombolysis is an effective treatment for hemodynamically unstable, high-risk PE, but is associated with bleeding complications. USAT is thought to reduce bleeding and is therefore advocated in patients with high-risk PE and contraindications for systemic thrombolysis. Methods We conducted a retrospective cohort study of all patients who underwent USAT for high-risk PE in the Netherlands from 2010 to 2017. Characteristics and outcomes were analyzed. Primary outcomes were major (including intracranial and fatal) bleeding and all-cause mortality after 1 month. Secondary outcomes were allcause mortality and recurrent venous thromboembolism within 3 months. Results 33 patients underwent USAT for high-risk PE. Major bleeding occurred in 12 patients (36%, 95% CI 22–53), including 1 intracranial and 3 fatal bleeding. Allcause mortality after 1 month was 48% (16/33, 95% CI 31–66). All-cause mortality after 3 months was 50% (16/ 32, 95% CI 34–66), recurrent venous thromboembolism occurred in 1 patient (1/32, 3%, 95% CI 1–16). Conclusions This study was the first to describe characteristics and outcomes after USAT in a study population of patients with high-risk PE only, an understudied population. Although USAT is considered a relatively safe treatment option, our results illustrate that at least caution is needed in critically ill patients with high-risk PE. Further research in patients with high-risk PE is warranted to guide patient selection

Cardiothoracic CT: one-stop-shop procedure? Impact on the management of acute pulmonary embolism

In the treatment of pulmonary embolism (PE) two groups of patients are traditionally identified, namely the hemodynamically stable and instable groups. However, in the large group of normotensive patients with PE, there seems to be a subgroup of patients with an increased risk of an adverse outcome, which might benefit from more aggressive therapy than the current standard therapy with anticoagulants. Risk stratification is a commonly used method to define subgroups of patients with either a high or low risk of an adverse outcome. In this review the clinical parameters and biomarkers of myocardial injury and right ventricular dysfunction (RVD) that have been suggested to play an important role in the risk stratification of PE are described first. Secondly, the use of more direct imaging techniques like echocardiography and CT in the assessment of RVD are discussed, followed by a brief outline of new imaging techniques. Finally, two risk stratification models are proposed, combining the markers of RVD with cardiac biomarkers of ischemia to define whether patients should be admitted to the intensive care unit (ICU) and/or be given thrombolysis, admitted to the medical ward, or be safely treated at home with anticoagulant therapy

Predictors of bleeding complications during catHeter-dirEcted thrombolysis for peripheral arterial occlusions (POCHET)

Introduction The risk of major bleeding complications in catheter directed thrombolysis (CDT) for acute limb ischemia (ALI) remains high, with reported major bleeding complication rates in up to 1 in every 10 treated patients. Fibrinogen was the only predictive marker used for bleeding complications in CDT, despite the lack of high quality evidence to support this. Therefore, recent international guidelines recommend against the use of fibrinogen during CDT. However, no alternative biomarkers exist to effectively predict CDT-related bleeding complications. The aim of the POCHET biobank is to prospectively assess the rate and etiology of bleeding complications during CDT and to provide a biobank of blood samples to investigate potential novel biomarkers to predict bleeding complications during CDT. Methods The POCHET biobank is a multicentre prospective biobank. After informed consent, all consecutive patients with lower extremity ALI eligible for CDT are included. All patients are treated according to a predefined standard operating procedure which is aligned in all participating centres. Baseline and follow-up data are collected. Prior to CDT and subsequently every six hours, venous blood samples are obtained and stored in the biobank for future analyses. The primary outcome is the occurrence of non-access related major bleeding complications, which is assessed by an independent adjudication committee. Secondary outcomes are non-major bleeding complications and other CDT related complications. Proposed biomarkers to be investigated include fibrinogen, to end the debate on its usefulness, anti-plasmin and D-Dimer. Discussion and conclusion The POCHET biobank provides contemporary data and outcomes of patients during CDT for ALI, coupled with their blood samples taken prior and during CDT. Thereby, the POCHET biobank is a real world monitor on biomarkers during CDT, supporting a broad spectrum of future research for the identification of patients at high risk for bleeding complications during CDT and to identify new biomarkers to enhance safety in CDT treatment

Current practice patterns of outpatient management of acute pulmonary embolism: A post-hoc analysis of the YEARS study

Background: Studies have shown the safety of home treatment of patients with pulmonary embolism (PE) at low risk of adverse events. Management studies focusing on home treatment have suggested that 30% to 55% of acute PE patients could be treated at home, based on the HESTIA criteria, but data from day-to-day clinical practice are largely unavailable. Aim: To determine current practice patterns of home treatment of acute PE in the Netherlands. Method: We performed a post-hoc analysis of the YEARS study. The main outcomes were the proportion of patients who were discharged <24 h and reasons for admission if treated in hospital. Further, we compared the 3-month incidence of PE-related unscheduled readmissions between patients treated at home and in hospital. Results: Of the 404 outpatients with PE included in this post-hoc analysis of the YEARS study, 184 (46%) were treated at home. The median duration of admission of the hospitalized patients was 3.0 days. The rate of PE-related readmissions of patients treated at home was 9.7% versus 8.6% for hospitalized patients (crude hazard ratio 1.1 (95% CI 0.57–2.1)). The 3-month incidence of any adverse event was 3.8% in those treated at home (2 recurrent VTE, 3 major bleedings and two deaths) compared to 10% in the hospitalized patients (3 recurrent VTE, 6 major bleedings and fourteen deaths). Conclusions: In the YEARS study, 46% of patients with PE were treated at home with low incidence of adverse events. PE-related readmission rates were not different between patients treated at home or in hospital

Cost-effectiveness of performing reference ultrasonography in patients with deep vein thrombosis

Background The diagnosis of recurrent ipsilateral deep vein thrombosis (DVT) with compression ultrasonography (CUS) may be hindered by residual intravascular obstruction after previous DVT. A reference CUS, an additional ultrasound performed at anticoagulant discontinuation, may improve the diagnostic work-up of suspected recurrent ipsilateral DVT by providing baseline images for future comparison.Objectives To evaluate the cost-effectiveness of routinely performing reference CUS in DVT patients.Methods Patient-level data (n 1/4 96) from a prospective management study (Theia study; NCT02262052) and claims data were used in a decision analytic model to compare 12 scenarios for diagnostic management of suspected recurrent ipsilateral DVT. Estimated health care costs and mortality due to misdiagnosis, recurrent venous thromboembolism, and bleeding during the first year of follow-up after presentation with suspected recurrence were compared.Results All six scenarios including reference CUS had higher estimated 1-year costs (1,763-1,913) than the six without reference CUS (1,192-1,474). Costs were higher because reference CUS results often remained unused, as 20% of patients (according to claims data) would return with suspected recurrent DVT. Estimated mortality was comparable in scenarios with (14.8-17.9 per 10,000 patients) and without reference CUS (14.0-18.5 per 10,000). None of the four potentially most desirable scenarios included reference CUS. Conclusion One-year health care costs of diagnostic strategies for suspected recurrent ipsilateral DVT including reference CUS are higher compared to strategies without reference CUS, without mortality benefit. These results can inform policy-makers regarding use of health care resources during follow-up after DVT. From a cost-effectiveness perspective, the findings do not support the routine application of reference CUS.Thrombosis and Hemostasi

The diagnostic management of suspected pulmonary embolism

Pulmonary embolism is a potentially fatal disease in which early recognition and institution of anticoagulant treatment can prevent mortality. The diagnostic tools available to establish whether a patient has a pulmonary embolism were limited to pulmonary angiography and ventilation-perfusion scintigraphy. Both tests have considerable limitations. Helical CT evolved as a new technique in diagnosing PE and gained widespread interest but has been implemented rapidly, without appropriate assessment in clinical practice. The Christopher-study was performed to investigate whether a dichotomization of the Wells clinical decision rule, classifying patients into __PE unlikely__ and __PE likely__ in combination with a D-dimer test is safe to rule out pulmonary embolism in patients with a clinical suspicion. Furthermore, the study was designed to investigate whether helical CT is safe to rule out PE without performing any additional diagnostic tests. In patients in whom PE was excluded by a clinical decision rule indicating __PE unlikely__ combined with a negative D-dimer, during three months of follow-up venous thrombo-embolism was diagnosed in 5 out of 1028 untreated patients (0.5%, 95%CI: 0.2-1.1). In patients in whom CT had ruled out PE, during three months follow-up 18 of 1446 untreated patients experienced a venous thrombo-embolic event (1.3%, 95%CI: 0.7-2.0). In conclusion, the Christopher-study demonstrates that a simple diagnostic algorithm consisting of a dichotomised clinical decision rule, D-dimer and helical CT can guide treatment decisions with a low risk of subsequent venous thrombo-embolism