Pulmonary Embolism: Next Generation
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Pulmonary Embolism: Next Generation
Jan. 28, 2020•0 likes•3,015 views
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Health & Medicine
This talk introduces the concept of a new generation of pulmonary embolism (PE). What was once considered a deadly disease process now carries a mortality rate of <3%, which may be driven by overtesting as well as overdiagnosis. This talk will explore this phenomenon and current evidence-based approaches to the evaluation and treatment of PEs.
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Pulmonary Embolism: Next Generation
- Lauren Westafer, DO, MPH, MS @LWestafer PE NEXTGENERATION
- NHLBI 1K12HL138049-01 $
- PE NEXTGENERATION
- diagnosis of less severe (and nonexistent) PEs Schissler AJ. PLoS One. 2013;8(6):e65669.
- 2004 2009 PEs/10,000EDvisits diagnosis of less severe PEs Schissler AJ. PLoS One. 2013;8(6):e65669.
- 2004 2009 PEs with RV strain PEs/10,000EDvisits diagnosis of less severe PEs Schissler AJ. PLoS One. 2013;8(6):e65669.
- 2004 2009 no RV strainPEs with RV strain PEs/10,000EDvisits diagnosis of less severe PEs Schissler AJ. PLoS One. 2013;8(6):e65669.
- overtested overdiagnosed overtreated PE NEXTGENERATION
- TESTED OVER
- 1993 1998 2006 # of PEs
- 1993 1998 2006 # of PEs
- 1993 1998 2006 # of PEs truth
- CTPA yield CTPA yield 9-25% NICE recommendations target 15.4 - 30%
- CTPA yield
- CTPA yield 2-10%
- CTPA yield 2-10% 10-17%
- CTPA yield 2-10% 10-17% 9-25%
- CTPA yield 2-10% 10-17% 9-25% 10-31%
- CTPA yield 2-10% 10-17% 9-25% 17% 10-31%
- CTPA yield 2-10% 10-17% 9-25% 39% 17% 10-31%
- risk stratification
- risk stratification harm of testing > benefit
- risk stratification harm of testing > benefit probability of PE < 1.8%
- risk stratification
- risk stratification Wells
- risk stratification Wells PERC
- risk stratification Wells PERC age adjusted d-dimer
- YEARS risk stratified d-dimer van der Hulle T et al. Lancet 2017;390(10091):289–97.
- YEARS no hemoptysis no DVT PE is most likely diagnosis d dimer cut off of 1000 ng/mL if…. van der Hulle T et al. Lancet 2017;390(10091):289–97. Kabrhel C et al.Acad Emerg Med. 2018;25(9):987–94.
- YEARSin pregnant patients! van der Pol LM et al. N Engl J Med. 2019;380(12):1139–49.
- Murphy N, et al.. BJOG. 2015;122:395–400.Available from: http://dx.doi.org/
- Murphy N, et al.. BJOG. 2015;122:395–400.Available from: http://dx.doi.org/
- Murphy N, et al.. BJOG. 2015;122:395–400.Available from: http://dx.doi.org/ NORMAL d-dimer in pregnancy
- YEARSin pregnant patients! van der Pol LM et al. N Engl J Med. 2019;380(12):1139–49.
- YEARSin pregnant patients! van der Pol LM et al. N Engl J Med. 2019;380(12):1139–49. prevented imaging in 65% 1st trimester 46% 2nd trimester 32% 3rd trimester
- risk stratification Wang RC et al.Ann Emerg Med. 2016;67(6):693–701. Buchanan I, et al.Acad Emerg Med 2017;24(11):1369–76. Goehler et al.Acad Radiol 2018;06519:1–7.
- risk stratification CTPA yield Wang RC et al.Ann Emerg Med. 2016;67(6):693–701. Buchanan I, et al.Acad Emerg Med 2017;24(11):1369–76. Goehler et al.Acad Radiol 2018;06519:1–7.
- risk stratification we override it in 25-96% of patients* CTPA yield Wang RC et al.Ann Emerg Med. 2016;67(6):693–701. Buchanan I, et al.Acad Emerg Med 2017;24(11):1369–76. Goehler et al.Acad Radiol 2018;06519:1–7.
- risk stratification we override it in 25-96% of patients* (mostly in the US) CTPA yield Wang RC et al.Ann Emerg Med. 2016;67(6):693–701. Buchanan I, et al.Acad Emerg Med 2017;24(11):1369–76. Goehler et al.Acad Radiol 2018;06519:1–7.
- DIAGNOSED OVER
- that PE… may not be real
- ..hours later1st scan
- ..hours later1st scan
- false + CTPA for PE 5-26%Gimber LH et al. . Perm J [Internet] 2009;13(4):4–10. Costantino G et alAm J Emerg Med [Internet] 2009;27(9):1109–11. Ruiz Y et al. Eur Radiol 2003;13(4):823–9. Ghanima et al. Acta radiol 2007;48(2):165–70. Hutchinson et al. Am J Roentgenol 2015;205(2):271–7.
- k=0.21 Ruiz Y, et al. Eur Radiol 2003;13(4):823–9. subsegmental clots CTPA interrater reliability
- it ain’t just subsegmental clots! k=0.4 - 0.8 Ruiz Y, et al. Eur Radiol 2003;13(4):823–9. Chartrand-lefebvre C, . Detection : Experience. 1999;(January). segmental
- false + PEs are.. highly illogical
- the problem with false + PEs… unnecessary anticoagulation
- the problem with false + PEs… unnecessary anticoagulation bleeding
- the problem with false + PEs… “history ofVTE”
- “i have chest pain”
- “i have chest pain”
- “i’m short of breath and have pneumonia”
- “i’m short of breath and have pneumonia”
- “i sprained my ankle and i’m tachycardic”
- “i sprained my ankle and i’m tachycardic”
- TREATED OVER
- subsegmental clots Kearon. Chest. 2016. Wolf SJ, et al.Ann Emerg Med 2018;71(5):e59–109. without DVT consider treatment based on individual risk factors
- PESI class I/II outpatient treatment sPESI 0 Hestia criteria Simková I, et al. Eur Heart J 2014;35(43):3033–73. Kearoon. Chest 2016 Davies C et al. BMJ Open Respir Res 2018;5(1):e000281.
- PEovertested overdiagnosed overtreated
- PEovertested overdiagnosed overtreated
- PEovertested overdiagnosed overtreated understand risk of false positives of CTPA testing rationally and treating conservatively
- PEtest rationally and prosper