IU Indianapolis ScholarWorks :: Browsing by Subject "pulmonary embolism"

Browsing by Subject "pulmonary embolism"

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Clinical Characteristics, Management, and Outcomes of Patients Diagnosed With Acute Pulmonary Embolism in the Emergency Department
(2011-02) Pollack, Charles V; Schreiber, Donald; Goldhaber, Samuel Z; Slattery, David; Fanikos, John; O'Neil, Brian J; Thompson, James R; Hiestand, Brian; Briese, Beau A; Pendleton, Robert C; Miller, Chadwick D; Kline, Jeffrey A.
Objectives In a large U.S. sample, this study measured the presentation features, testing, treatment strategies, and outcomes of patients diagnosed with pulmonary embolism (PE) in the emergency department (ED). Background No data have quantified the demographics, clinical features, management, and outcomes of outpatients diagnosed with PE in the ED in a large, multicenter U.S. study. Methods Patients of any hemodynamic status were enrolled from the ED after confirmed acute PE or with a high clinical suspicion prompting anticoagulation before imaging for PE. Exclusions were inability to provide informed consent (where required) or unavailability for follow-up. Results A total of 1,880 patients with confirmed acute PE were enrolled from 22 U.S. EDs. Diagnosis of PE was based upon positive results of computerized tomographic pulmonary angiogram in most cases (n = 1,654 [88%]). Patients represented both sexes equally, and racial and ethnic composition paralleled the overall U.S. ED population. Most (79%) patients with PE were employed, and one-third were older than age 65 years. The mortality rate directly attributed to PE was 20 in 1,880 (1%; 95% confidence interval [CI]: 0% to 1.6%). Mortality from hemorrhage was 0.2%, and the all-cause 30-day mortality rate was 5.4% (95% CI: 4.4% to 6.6%). Only 3 of 20 patients with major PE that ultimately proved fatal had systemic anticoagulation initiated before diagnostic confirmation, and another 3 of these 20 received a fibrinolytic agent. Conclusions Patients diagnosed with acute PE in U.S. EDs have high functional status, and their mortality rate is low. These registry data suggest that appropriate initial medical management of ED patients with severe PE with anticoagulation is poorly standardized and indicate a need for research to determine the appropriate threshold for empiric treatment when PE is suspected before diagnostic confirmation.
Clinical features from the history and physical examination that predict the presence or absence of pulmonary embolism in symptomatic emergency department patients: results of a prospective, multi-center study
(2010-04) Courtney, Mark; Kline, Jeffrey A.; Kabrhel, Christopher; Moore, Christopher L; Smithline, Howard A; Nordenholz, Kristen E; Richman, Peter B; Plewa, Michael C
Study Objective—Prediction rules for pulmonary embolism (PE) employ variables explicitly shown to estimate the probability of PE. However, clinicians often use variables that have not been similarly validated, yet are implicitly believed to modify probability of PE. The objective of this study was to measure the predictive value of 13 implicit variables. Methods—Patients were enrolled in a prospective cohort study from 12 centers in the United States; all had an objective test for PE (D-dimer, CT angiography, or V/Q scan). Clinical features including 12 predefined previously validated (explicit) variables and 13 variables not part of existing prediction rules (implicit) were prospectively recorded at presentation. The primary outcome was VTE (venous thromboembolism: PE or deep venous thrombosis), diagnosed by imaging up to 45 days after enrollment. Variables with adjusted odds ratios from logistic regression with 95% confidence intervals not crossing unity were considered significant. Results—7,940 patients (7.2% VTE+) were enrolled. Mean age was 49±17 years and 67% were female. Eight of 13 implicit variables were significantly associated with VTE; those with an adjusted OR >1.5 included non-cancer related thrombophilia (1.99), pleuritic chest pain (1.53), and family history of VTE (1.51). Implicit variables that predicted no VTE outcome included: substernal chest pain, female gender, and smoking. Nine of 12 explicit variables predicted a positive outcome of VTE, including unilateral leg swelling, recent surgery, estrogen, hypoxemia and active malignancy. Conclusions—In symptomatic outpatients being considered for possible PE, non-cancer related thrombophilia, pleuritic chest pain, and family history of VTE increase probability of PE or DVT. Other variables that are part of existing pretest probability systems were validated as important predictors in this diverse sample of US Emergency department patients.
D-Dimer and Exhaled CO2/O2 to Detect Segmental Pulmonary Embolism in Moderate-Risk Patients
(2010-09) Kline, Jeffrey A.; Hogg, Melanie M; Courtney, D Mark; Miller, Chadwick D; Jones, Alan E; Smithline, Howard A; Klekowski, Nicole; Lanier, Randy
Rationale: Pulmonary embolism (PE) decreases the exhaled end-tidal ratio of carbon dioxide to oxygen (etCO2/O2). Objectives: To test if the etCO2/O2 can produce clinically important changes in the probability of segmental or larger PE on computerized tomography multidetector-row pulmonary angiography (MDCTPA) in a moderate-risk population with a positive D-dimer. Methods: Emergency department and hospitalized patients with one or more predefined symptoms or signs, one or more risk factors for PE, and 64-slice MDCTPA enrolled from four hospitals. D-dimer greater than 499 ng/ml was test(+), and D-dimer less than 500 ng/ml was test(−). The median etCO2/O2 less than 0.28 from seven or more breaths was test(+) and etCO2/O2 greater than 0.45 was test(−). MDCTPA images were read by two independent radiologists and the criterion standard was the interpretation of acute PE by either reader. PE size was then graded. Measurements and Main Results: We enrolled 495 patients, including 60 (12%) with segmental or larger, and 29 (6%) with subsegmental PE. A total of 367 (74%) patients were D-dimer(+), including all 60 with segmental or larger PE (posterior probability 16%). The combination of D-dimer(+) and etCO2/O2(+) increased the posterior probability of segmental or larger PE to 28% (95% confidence interval [CI] for difference of 12%, 3.0–22%). The combination of D-dimer(+) and etCO2/O2(−) was observed in 40 patients (8%; 95% CI, 6–11%), and none (0/40; 95% CI, 0–9%) had segmental or larger PE on MDCTPA. No strategy changed the prevalence of subsegmental PE. Conclusions: In moderate-risk patients with a positive D-dimer, the et etCO2/O2 less than 0.28 significantly increases the probability of segmental or larger PE and the etCO2/O2 greater than 0.45 predicts the absence of segmental or larger PE on MDCTPA.
D-dimer threshold increase with pretest probability unlikely for pulmonary embolism to decrease unnecessary computerized tomographic pulmonary angiography
(2012-04) Kline, Jeffrey A.; Hogg, Melanie M; Courtney, D Mark; Miller, Chadwick D; Jones, Alan E; Smithline, Howard A
Background: Increasing the threshold to define a positive D-dimer could reduce unnecessary computed tomographic pulmonary angiography (CTPA) for a suspected pulmonary embolism (PE) but might increase rates of a missed PE and missed pneumonia, the most common non-thromboembolic diagnosis seen on CTPA. Objective: Measure the effect of doubling the standard D-dimer threshold for ‘PE unlikely’ Revised Geneva (RGS) or Wells’ scores on the exclusion rate, frequency and size of a missed PE and missed pneumonia. Methods: Patients evaluated for a suspected PE with 64-channel CTPA were prospectively enrolled from emergency departments (EDs) and inpatient units of four hospitals. Pretest probability data were collected in real time and the D-dimer was measured in a central laboratory. Criterion standard was CPTA interpretation by two independent radiologists combined with clinical outcome at 30 days. Results: Of 678 patients enrolled, 126 (19%) were PE+ and 93 (14%) had pneumonia. Use of either Wells’ ≤ 4 or RGS ≤ 6 produced similar results. For example, with RGS ≤ 6 and standard threshold (< 500 ng mL−1), D-dimer was negative in 110/678 (16%), and 4/110 were PE+ (posterior probability 3.8%) and 9/110 (8.2%) had pneumonia. With RGS ≤ 6 and a threshold < 1000 ng mL−1, D-dimer was negative in 208/678 (31%) and 11/208 (5.3%) were PE+, but 10/11 missed PEs were subsegmental and none had concomitant DVT. Pneumonia was found in 12/208 (5.4%) with RGS ≤ 6 and D-dimer < 1000 ng mL−1. Conclusions: Doubling the threshold for a positive D-dimer with a PE unlikely pretest probability could reduce CTPA scanning with a slightly increased risk of missed isolated subsegmental PE, and no increase in rate of missed pneumonia.
Derivation and validation of a multivariate model to predict mortality from pulmonary embolism with cancer: the POMPE-C tool
(2012-05) Kline, Jeffrey A.; Roy, Pierre-Marie; Than, Martin P; Hernandez, Jackeline; Courtney, D Mark; Jones, Alan E; Penazola, Andrea; Pollack Jr, Charles V
Background Clinical guidelines recommend risk stratification of patients with acute pulmonary embolism (PE). Active cancer increases risk of PE and worsens prognosis, but also causes incidental PE that may be discovered during cancer staging. No quantitative decision instrument has been derived specifically for patients with active cancer and PE. Methods Classification and regression technique was used to reduce 25 variables prospectively collected from 408 patients with AC and PE. Selected variables were transformed into a logistic regression model, termed POMPE-C, and compared with the pulmonary embolism severity index (PESI) score to predict the outcome variable of death within 30 days. Validation was performed in an independent sample of 182 patients with active cancer and PE. Results POMPE-C included eight predictors: body mass, heart rate > 100, respiratory rate, SaO2%, respiratory distress, altered mental status, do not resuscitate status, and unilateral limb swelling. In the derivation set, the area under the ROC curve for POMPE-C was 0.84 (95% CI: 0.82-0.87), significantly greater than PESI (0.68, 0.60-0.76). In the validation sample, POMPE-C had an AUC of 0.86 (0.78-0.93). No patient with POMPE-C estimate ≤ 5% died within 30 days (0/50, 0-7%), whereas 10/13 (77%, 46-95%) with POMPE-C estimate > 50% died within 30 days. Conclusion In patients with active cancer and PE, POMPE-C demonstrated good prognostic accuracy for 30 day mortality and better performance than PESI. If validated in a large sample, POMPE-C may provide a quantitative basis to decide treatment options for PE discovered during cancer staging and with advanced cancer.
Development and comparison of a minimallyinvasive model of autologous clot pulmonary embolism in Sprague-Dawley and Copenhagen rats
(2010-02) Runyon, Michael S; Gellar, Michael A; Sanapareddy, Nina; Kline, Jeffrey A.; Watts, John A
Background Experimental models of pulmonary embolism (PE) that produce pulmonary hypertension (PH) employ many different methods of inducing acute pulmonary occlusion. Many of these models induce PE with intravenous injection of exogenous impervious objects that may not completely reproduce the physiological properties of autologous thromboembolism. Current literature lacks a simple, well-described rat model of autlogous PE. Objective: Test if moderate-severity autologous PE in Sprague-Dawley (SD) and Copenhagen (Cop) rats can produce persistent PH. Methods blood was withdrawn from the jugular vein, treated with thrombin-Ca++ and re-injected following pretreatment with tranexamic acid. Hemodynamic values, clot weights and biochemical measurements were performed at 1 and 5 days. Results Infusion of clot significantly increased the right ventricular peak systolic pressure to 45-55 mm Hg, followed by normalization within 24 hours in SD rats, and within 5 days in COP rats. Clot lysis was 95% (24 hours) and 97% (5 days) in SD rats and was significantly lower in COP rats (70%, 24 hours; 87% 5 days). Plasma D-dimer was elevated in surgical sham animals and was further increased 8 hours after pulmonary embolism. Neither strain showed a significant increase in bronchoalveolar chemotactic activity, myeloperoxidase activity, leukocyte infiltration, or chemokine accumulation, indicating that there was no significant pulmonary inflammation. Conclusions Both SD and COP rats exhibited near complete fibrinolysis of autologous clot PE within 5 days. Neither strain developed persistent PH. Experimental models of PE designed to induce sustained PH and a robust inflammatory response appear to require significant, persistent pulmonary vascular occlusion.
Don't Always Depend on Your D-Dimer: An Atypical Case of Pulmonary Embolism
(2021-03) Willhite, Sydney; Betts, Aislinn; Lee, Maya; Juloori, Sangeeta
Case: A 35-year-old female patient, with current IV drug use and a history of endocarditis warranting tricuspid valve replacement, presented with dyspnea and chest pain. On physical exam, she was found to have scattered wheezes on expiration with no shortness of breath or LE edema. As the Wells’ score for PE revealed a moderate risk, CTA and D-dimer were obtained. CTA revealed low contrast uptake in the right pulmonary artery, most concerning for a PE. D-dimer and coagulation studies were normal, making DVT unlikely and PE questionable. Therefore, there was high suspicion for endocarditis with septic emboli. On day two, TEE showed no valvular vegetations or thrombus. With no evidence of endocarditis, DVT was reconsidered. Bilateral LE doppler ultrasounds were negative for DVT. However, a repeat D-dimer was found to be elevated (596 ng/mL). Clinical impression on day three was a PE secondary to a small superior venous thrombosis from IV drug use. Conclusions: IV drug use is recognized as a risk factor for SVT and DVT due to endothelial damage of injected veins and/or increased coagulation factors. As a LE DVT was ruled out through ultrasound, this patient likely had an UE thrombus with a secondary PE. However, her low D-dimer in the setting of a PE is puzzling considering the test’s high sensitivity (95%). Given that her subsequent D-dimer was elevated, this suggests that the initial test may have been inaccurate. Clinical Significance: D-dimer is considered to be a useful test to rule out DVT and PE in cases of low or moderate probability. However, a few reasons for false-normal D-dimer have been elicited: small emboli, anticoagulant pretreatment, and symptoms ongoing for ≥ 10 days. In this case with moderate probability, the initial falsely low D-dimer decreased suspicion for thrombosis and was most likely due to small emboli. Therefore, the causes of false-normal D-dimer must be well known and considered in order to avoid misdiagnosis.
Effects of angiotensin (1-7) upon right ventricular function in experimental rat pulmonary embolism
(2011) Watts, John A; Gellar, Michael A; Stuart, Lori; Obraztsova, Maria; Marchick, Michael R; Kline, Jeffrey A.
Right ventricular (RV) dysfunction contributes to poor clinical prognosis after pulmonary embolism (PE). The present studies evaluate the effects of angiotensin (1-7) (ANG (1-7)) upon RV function during experimental PE in rats. Circulating ANG II increased 8-fold 6 hr after PE (47±13 PE vs. 6±3 pg/mL, control, p<0.05). ACE2 protein was uniformly localized in the RV myocardium of control rats, but showed a patchy distribution with some cells devoid of stain after 6 or 18 hr of PE. RV function decreased 18 hr after PE compared with control treated animals (19±4 vs. 41±1 mmHg, respectively, p<0.05; 669±98 vs. 1354±77 mmHg/sec, respectively, p<0.05), while left ventricular function (LV) was not significantly changed. Animals treated with ANG (1-7) during PE showed improved RV +dP/dt and peak systolic pressure development to values not significantly different from control animals. Protection of RV function by ANG (1-7) was associated with improved arterial blood sO2, base excess and pH. Supplemental delivery of ANG (1-7) reduced the development of RV dysfunction, suggesting a novel approach to protecting RV function in the setting of acute experimental PE.
Emergency Department Cardiopulmonary Evaluation of Low-Risk Chest Pain Patients with Self-Reported Stress and Anxiety
(Elsevier, 2017-03) Musey, Paul I., Jr.; Kline, Jeffrey A.; Department of Emergency Medicine, School of Medicine
Background Chest pain is a high-risk emergency department (ED) chief complaint; the majority of clinical resources are directed toward detecting and treating cardiopulmonary emergencies. However, at follow-up, 80%–95% of these patients have only a symptom-based diagnosis; a large number have undiagnosed anxiety disorders. Objective Our aim was to measure the frequency of self-identified stress or anxiety among chest pain patients, and compare their pretest probabilities, care processes, and outcomes. Methods Patients were divided into two groups: explicitly self-reported anxiety and stress or not at 90-day follow-up, then compared on several variables: ultralow (<2.5%) pretest probability, outcome rates for acute coronary syndrome (ACS) and pulmonary embolism (PE), radiation exposure, total costs at 30 days, and 90-day recidivism. Results Eight hundred and forty-five patients were studied. Sixty-seven (8%) explicitly attributed their chest pain to “stress” or “anxiety”; their mean ACS pretest probability was 4% (95% confidence interval 2.9%–5.7%) and 49% (33/67) had ultralow pretest probability (0/33 with ACS or PE). None (0/67) were diagnosed with anxiety. Seven hundred and seventy-eight did not report stress or anxiety and, of these, 52% (403/778) had ultralow ACS pretest probability. Only one patient (0.2%; 1/403) was diagnosed with ACS and one patient (0.4%; 1/268) was diagnosed with PE. Patients with self-reported anxiety had similar radiation exposure, associated costs, and nearly identical (25.4% vs. 25.7%) ED recidivism to patients without reported anxiety. Conclusions Without prompting, 8% of patients self-identified “stress” or “anxiety” as the etiology for their chest pain. Most had low pretest probability, were over-investigated for ACS and PE, and not investigated for anxiety syndromes.
Evaluation of Pulmonary Embolism in the Emergency Department and Consistency With a National Quality Measure: Quantifying the opportunity for improvement
(2012-07) Venkatesh, Arjun K; Kline, Jeffrey A.; Courtney, D Mark; Camargo Jr, Carlos A; Plewa, Michael C; Nordenholz, Kristen E; Moore, Christopher L; Richman, Peter B; Smithline, Howard A; Beam, Daren M; Kabrhel, Christopher
Background The National Quality Forum (NQF) has endorsed a performance measure designed to increase imaging efficiency for the evaluation of pulmonary embolism (PE) in the emergency department (ED). To our knowledge, no published data have examined the effect of patient-level predictors on performance. Methods To quantify the prevalence of avoidable imaging in ED patients with suspected PE, we performed a prospective, multicenter observational study of ED patients evaluated for PE from 2004 through 2007 at 11 US EDs. Adult patients tested for PE were enrolled, with data collected in a standardized instrument. The primary outcome was the proportion of imaging that was potentially avoidable according to the NQF measure. Avoidable imaging was defined as imaging in a patient with low pretest probability for PE, who either did not have a D-dimer test ordered or who had a negative D-dimer test result. We performed subanalyses testing alternative pretest probability cutoffs and imaging definitions on measure performance as well as a secondary analysis to identify factors associated with inappropriate imaging. χ2 Test was used for bivariate analysis of categorical variables and multivariable logistic regression for the secondary analysis. Results We enrolled 5940 patients, of whom 4113 (69%) had low pretest probability of PE. Imaging was performed in 2238 low-risk patients (38%), of whom 811 had no D-dimer testing, and 394 had negative D-dimer test results. Imaging was avoidable, according to the NQF measure, in 1205 patients (32%; 95% CI, 31%-34%). Avoidable imaging owing to not ordering a D-dimer test was associated with age (odds ratio [OR], 1.15 per decade; 95% CI, 1.10-1.21). Avoidable imaging owing to imaging after a negative D-dimer test result was associated with inactive malignant disease (OR, 1.66; 95% CI, 1.11-2.49). Conclusions One-third of imaging performed for suspected PE may be categorized as avoidable. Improving adherence to established diagnostic protocols is likely to result in significantly fewer patients receiving unnecessary irradiation and substantial savings.

Browsing by Subject "pulmonary embolism"

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