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.

1. Lauren Westafer, DO, MPH, MS
@LWestafer
PE
NEXTGENERATION

2. NHLBI 1K12HL138049-01
$

3. PE
NEXTGENERATION

4. diagnosis of less severe
(and nonexistent)
PEs
Schissler AJ. PLoS One. 2013;8(6):e65669.

5. 2004 2009
PEs/10,000EDvisits
diagnosis of less severe PEs
Schissler AJ. PLoS One. 2013;8(6):e65669.

6. 2004 2009
PEs with RV strain
PEs/10,000EDvisits
diagnosis of less severe PEs
Schissler AJ. PLoS One. 2013;8(6):e65669.

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. overtested
overdiagnosed
overtreated
PE
NEXTGENERATION

9. TESTED
OVER

10. 1993 1998 2006
# of PEs

11. 1993 1998 2006
# of PEs

12. 1993 1998 2006
# of PEs
truth

13. CTPA yield
CTPA yield
9-25%
NICE recommendations
target 15.4 - 30%

14. CTPA yield

15. CTPA yield
2-10%

16. CTPA yield
2-10%
10-17%

17. CTPA yield
2-10%
10-17%
9-25%

18. CTPA yield
2-10%
10-17%
9-25%
10-31%

19. CTPA yield
2-10%
10-17%
9-25%
17%
10-31%

20. CTPA yield
2-10%
10-17%
9-25%
39%
17%
10-31%

21. risk stratification

22. risk stratification
harm of testing > benefit

23. risk stratification
harm of testing > benefit
probability of PE < 1.8%

24. risk stratification

25. risk stratification
Wells

26. risk stratification
Wells
PERC

27. risk stratification
Wells
PERC
age adjusted d-dimer

28. YEARS
risk stratified d-dimer
van der Hulle T et al. Lancet 2017;390(10091):289–97.

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. YEARSin pregnant patients!
van der Pol LM et al. N Engl J Med. 2019;380(12):1139–49.

31. Murphy N, et al.. BJOG. 2015;122:395–400.Available from: http://dx.doi.org/

32. Murphy N, et al.. BJOG. 2015;122:395–400.Available from: http://dx.doi.org/

33. Murphy N, et al.. BJOG. 2015;122:395–400.Available from: http://dx.doi.org/
NORMAL d-dimer in pregnancy

34. YEARSin pregnant patients!
van der Pol LM et al. N Engl J Med. 2019;380(12):1139–49.

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. 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. 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. 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. 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. DIAGNOSED
OVER

41. that PE…
may not be real

42. ..hours later1st scan

43. ..hours later1st scan

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. k=0.21
Ruiz Y, et al. Eur Radiol 2003;13(4):823–9.
subsegmental clots
CTPA interrater reliability

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. false + PEs are..
highly illogical

48. the problem with false + PEs…
unnecessary anticoagulation

49. the problem with false + PEs…
unnecessary anticoagulation
bleeding

50. the problem with false + PEs…
“history ofVTE”

51. “i have chest pain”

52. “i have chest pain”

53. “i’m short of breath and have
pneumonia”

54. “i’m short of breath and have
pneumonia”

55. “i sprained my ankle and i’m
tachycardic”

56. “i sprained my ankle and i’m
tachycardic”

57. TREATED
OVER

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. 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. PEovertested
overdiagnosed
overtreated

61. PEovertested
overdiagnosed
overtreated

62. PEovertested
overdiagnosed
overtreated
understand risk of false positives of CTPA
testing rationally
and treating conservatively

63. PEtest rationally and prosper