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Pulmonary Embolism: Next Generation

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

  1. 1. Lauren Westafer, DO, MPH, MS @LWestafer PE NEXTGENERATION
  2. 2. NHLBI 1K12HL138049-01 $
  3. 3. PE NEXTGENERATION
  4. 4. diagnosis of less severe (and nonexistent) PEs Schissler AJ. PLoS One. 2013;8(6):e65669.
  5. 5. 2004 2009 PEs/10,000EDvisits diagnosis of less severe PEs Schissler AJ. PLoS One. 2013;8(6):e65669.
  6. 6. 2004 2009 PEs with RV strain PEs/10,000EDvisits diagnosis of less severe PEs Schissler AJ. PLoS One. 2013;8(6):e65669.
  7. 7. 2004 2009 no RV strainPEs with RV strain PEs/10,000EDvisits diagnosis of less severe PEs Schissler AJ. PLoS One. 2013;8(6):e65669.
  8. 8. overtested overdiagnosed overtreated PE NEXTGENERATION
  9. 9. TESTED OVER
  10. 10. 1993 1998 2006 # of PEs
  11. 11. 1993 1998 2006 # of PEs
  12. 12. 1993 1998 2006 # of PEs truth
  13. 13. CTPA yield CTPA yield 9-25% NICE recommendations target 15.4 - 30%
  14. 14. CTPA yield
  15. 15. CTPA yield 2-10%
  16. 16. CTPA yield 2-10% 10-17%
  17. 17. CTPA yield 2-10% 10-17% 9-25%
  18. 18. CTPA yield 2-10% 10-17% 9-25% 10-31%
  19. 19. CTPA yield 2-10% 10-17% 9-25% 17% 10-31%
  20. 20. CTPA yield 2-10% 10-17% 9-25% 39% 17% 10-31%
  21. 21. risk stratification
  22. 22. risk stratification harm of testing > benefit
  23. 23. risk stratification harm of testing > benefit probability of PE < 1.8%
  24. 24. risk stratification
  25. 25. risk stratification Wells
  26. 26. risk stratification Wells PERC
  27. 27. risk stratification Wells PERC age adjusted d-dimer
  28. 28. YEARS risk stratified d-dimer van der Hulle T et al. Lancet 2017;390(10091):289–97.
  29. 29. 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.
  30. 30. YEARSin pregnant patients! van der Pol LM et al. N Engl J Med. 2019;380(12):1139–49.
  31. 31. Murphy N, et al.. BJOG. 2015;122:395–400.Available from: http://dx.doi.org/
  32. 32. Murphy N, et al.. BJOG. 2015;122:395–400.Available from: http://dx.doi.org/
  33. 33. Murphy N, et al.. BJOG. 2015;122:395–400.Available from: http://dx.doi.org/ NORMAL d-dimer in pregnancy
  34. 34. YEARSin pregnant patients! van der Pol LM et al. N Engl J Med. 2019;380(12):1139–49.
  35. 35. 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
  36. 36. 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.
  37. 37. 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.
  38. 38. 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.
  39. 39. 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.
  40. 40. DIAGNOSED OVER
  41. 41. that PE… may not be real
  42. 42. ..hours later1st scan
  43. 43. ..hours later1st scan
  44. 44. 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.
  45. 45. k=0.21 Ruiz Y, et al. Eur Radiol 2003;13(4):823–9. subsegmental clots CTPA interrater reliability
  46. 46. 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
  47. 47. false + PEs are.. highly illogical
  48. 48. the problem with false + PEs… unnecessary anticoagulation
  49. 49. the problem with false + PEs… unnecessary anticoagulation bleeding
  50. 50. the problem with false + PEs… “history ofVTE”
  51. 51. “i have chest pain”
  52. 52. “i have chest pain”
  53. 53. “i’m short of breath and have pneumonia”
  54. 54. “i’m short of breath and have pneumonia”
  55. 55. “i sprained my ankle and i’m tachycardic”
  56. 56. “i sprained my ankle and i’m tachycardic”
  57. 57. TREATED OVER
  58. 58. 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
  59. 59. 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.
  60. 60. PEovertested overdiagnosed overtreated
  61. 61. PEovertested overdiagnosed overtreated
  62. 62. PEovertested overdiagnosed overtreated understand risk of false positives of CTPA testing rationally and treating conservatively
  63. 63. PEtest rationally and prosper

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