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      Utilization of CT Pulmonary Angiography in Suspected Pulmonary Embolism in a Major Urban Emergency Department

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      Author(s): 1 , 2 , * , 3 , 3
      Publication date (Electronic):
      Journal: Pulmonary Medicine
      Publisher: Hindawi Publishing Corporation

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          Abstract

          Objectives. We conducted a study to answer 3 questions: (1) is CT pulmonary angiography (CTPA) overutilized in suspected pulmonary embolism (PE)? (2) What alternative diagnoses are provided by CTPA? (3) Can CTPA be used to evaluate right ventricular dilatation (RVD)? Methods. We retrospectively reviewed the clinical information of 231 consecutive emergency department patients who underwent CTPA for suspected PE over a one-year period. Results. The mean age of our patients was 53 years, and 58.4% were women. The prevalence of PE was 20.7%. Among the 136 patients with low clinical probability of PE, a d-dimer test was done in 54.4%, and it was normal in 24.3%; none of these patients had PE. The most common alternative findings on CTPA were emphysema (7.6%), pneumonia (7%), atelectasis (5.5%), bronchiectasis (3.8%), and congestive heart failure (3.3%). The sensitivity and negative predictive value of CTPA for (RVD) was 92% and 80%, respectively. Conclusions. PE could have been excluded without CTPA in ~1 out of 4 patients with low clinical probability of PE, if a formal assessment of probability and d-dimer test had been done. In patients without PE, CTPA did not provide an alternative diagnosis in 65%. In patients with PE, CTPA showed the potential to evaluate RVD.

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          Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer.

          P. S. Wells, D Anderson, M. Rodger … (2000)
          We have previously demonstrated that a clinical model can be safely used in a management strategy in patients with suspected pulmonary embolism (PE). We sought to simplify the clinical model and determine a scoring system, that when combined with D-dimer results, would safely exclude PE without the need for other tests, in a large proportion of patients. We used a randomly selected sample of 80% of the patients that participated in a prospective cohort study of patients with suspected PE to perform a logistic regression analysis on 40 clinical variables to create a simple clinical prediction rule. Cut points on the new rule were determined to create two scoring systems. In the first scoring system patients were classified as having low, moderate and high probability of PE with the proportions being similar to those determined in our original study. The second system was designed to create two categories, PE likely and unlikely. The goal in the latter was that PE unlikely patients with a negative D-dimer result would have PE in less than 2% of cases. The proportion of patients with PE in each category was determined overall and according to a positive or negative SimpliRED D-dimer result. After these determinations we applied the models to the remaining 20% of patients as a validation of the results. The following seven variables and assigned scores (in brackets) were included in the clinical prediction rule: Clinical symptoms of DVT (3.0), no alternative diagnosis (3.0), heart rate >100 (1.5), immobilization or surgery in the previous four weeks (1.5), previous DVT/PE (1.5), hemoptysis (1.0) and malignancy (1.0). Patients were considered low probability if the score was 4.0. 7.8% of patients with scores of less than or equal to 4 had PE but if the D-dimer was negative in these patients the rate of PE was only 2.2% (95% CI = 1.0% to 4.0%) in the derivation set and 1.7% in the validation set. Importantly this combination occurred in 46% of our study patients. A score of <2.0 and a negative D-dimer results in a PE rate of 1.5% (95% CI = 0.4% to 3.7%) in the derivation set and 2.7% (95% CI = 0.3% to 9.0%) in the validation set and only occurred in 29% of patients. The combination of a score < or =4.0 by our simple clinical prediction rule and a negative SimpliRED D-Dimer result may safely exclude PE in a large proportion of patients with suspected PE.
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            Recurrent CT, cumulative radiation exposure, and associated radiation-induced cancer risks from CT of adults.

            Katherine P Andriole, Aaron D Sodickson, Richard Hanson … (2009)
            To estimate cumulative radiation exposure and lifetime attributable risk (LAR) of radiation-induced cancer from computed tomographic (CT) scanning of adult patients at a tertiary care academic medical center. This HIPAA-compliant study was approved by the institutional review board with waiver of informed consent. The cohort comprised 31,462 patients who underwent diagnostic CT in 2007 and had undergone 190,712 CT examinations over the prior 22 years. Each patient's cumulative CT radiation exposure was estimated by summing typical CT effective doses, and the Biological Effects of Ionizing Radiation (BEIR) VII methodology was used to estimate LAR on the basis of sex and age at each exposure. Billing ICD9 codes and electronic order entry information were used to stratify patients with LAR greater than 1%. Thirty-three percent of patients underwent five or more lifetime CT examinations, and 5% underwent between 22 and 132 examinations. Fifteen percent received estimated cumulative effective doses of more than 100 mSv, and 4% received between 250 and 1375 mSv. Associated LAR had mean and maximum values of 0.3% and 12% for cancer incidence and 0.2% and 6.8% for cancer mortality, respectively. CT exposures were estimated to produce 0.7% of total expected baseline cancer incidence and 1% of total cancer mortality. Seven percent of the cohort had estimated LAR greater than 1%, of which 40% had either no malignancy history or a cancer history without evidence of residual disease. Cumulative CT radiation exposure added incrementally to baseline cancer risk in the cohort. While most patients accrue low radiation-induced cancer risks, a subgroup is potentially at higher risk due to recurrent CT imaging.
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              Short-term clinical outcome of patients with acute pulmonary embolism, normal blood pressure, and echocardiographic right ventricular dysfunction.

              Stefano Grifoni, Iacopo Olivotto, Paolo Cecchini … (2000)
              The role of echocardiographic right ventricular (RV) dysfunction in predicting clinical outcome in clinically stable patients with pulmonary embolism (PE) is undefined. In this study, we assessed the prevalence and clinical outcome of normotensive patients with RV dysfunction among a broad spectrum of PE patients. This prospective clinical outcome study included cohort of 209 consecutive patients (age, 65+/-15 years) with documented PE. Acute RV dysfunction was diagnosed in the presence of >/=1 of the following: RV dilatation (without hypertrophy), paradox septal systolic motion, and Doppler evidence of pulmonary hypertension. Four groups were identified: 28 patients presenting with shock or cardiac arrest (13%), 19 hypotensive patients without shock (9%), 65 normotensive patients with echocardiographic RV dysfunction (31%), and 97 normotensive patients without RV dysfunction (47%). Among normotensive patients with RV dysfunction, 6 (10%) developed PE-related shock after admission: 3 of these patients died, and 3 were successfully treated with thrombolytic agents. In comparison, none of the 97 normotensive patients without RV dysfunction developed shock or died as a result of PE. A significant proportion (31%) of normotensive patients with acute PE presents with RV dysfunction; these patients with latent hemodynamic impairment have a 10% rate of PE-related shock and 5% in-hospital mortality and may require aggressive therapeutic strategies. Conversely, normotensive patients without echocardiographic RV dysfunction have a benign short-term prognosis. Thus, early detection of echocardiographic RV dysfunction is of major importance in the risk stratification of normotensive patients with acute PE.
              Article 0 comments Cited 102 times – based on 0 reviews     Review now
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                Author and article information

                Journal
                Journal ID (nlm-ta): Pulm Med
                Journal ID (iso-abbrev): Pulm Med
                Journal ID (publisher-id): PM
                Title: Pulmonary Medicine
                Publisher: Hindawi Publishing Corporation
                ISSN (Print): 2090-1836
                ISSN (Electronic): 2090-1844
                Publication date (Print): 2013
                Publication date (Electronic): 29 August 2013
                Volume: 2013
                Electronic Location Identifier: 915213
                Affiliations
                1Division of Pulmonary and Critical Care Medicine, College of Medicine at Jacksonville, University of Florida, Jacksonville, FL, USA
                2University of Florida, Shands Clinical Center, 655 West 8th Street, Suite 7-088, Jacksonville, FL 32209, USA
                3Division of Pulmonary and Critical Care Medicine, St. Luke's and Roosevelt Hospitals of Columbia University, New York, NY, USA
                Author notes

                Academic Editor: Nicole S. L. Goh

                Author information
                http://orcid.org/0000-0002-1048-1990
                Article
                DOI: 10.1155/2013/915213
                PMC ID: 3783975
                PubMed ID: 24078873
                SO-VID: 4db8589b-26dd-4f7c-9b9a-eb12955e783a
                Copyright © Copyright © 2013 Adil Shujaat et al.
                License:

                This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 7 March 2013
                Date accepted : 28 July 2013
                Categories
                Subject: Clinical Study

                ScienceOpen disciplines: Respiratory medicine
                Data availability:
                ScienceOpen disciplines: Respiratory medicine

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