Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Suspected Acute Venous Thromboembolic Disease.

Published on May 1, 2018in Annals of Emergency Medicine5.721
路 DOI :10.1016/J.ANNEMERGMED.2018.03.006
Stephen J. Wolf17
Estimated H-index: 17
Sigrid A. Hahn8
Estimated H-index: 8
+ 3 AuthorsMichael D. Brown30
Estimated H-index: 30
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#1Jeffrey A. Kline (IU: Indiana University)H-Index: 78
Abstract Background Failure to test for pulmonary embolism (PE) can be a lethal mistake, but PE and produces symptoms similar to many other diseases. Overtesting for PE has negative consequences. Objectives Use published evidence to create a rationale and safe diagnostic approach for ambulatory and emergency patients with suspected PE in 2017. Findings Pulmonary embolism need not be pursued in patients with no symptoms of PE in the present or recent history (dyspnea, chest pain, cough or syncope...
#1Deisy Barrios (University of Alcal谩)H-Index: 13
#2Raquel Morillo (University of Alcal谩)H-Index: 11
Last. David Jim茅nez (University of Alcal谩)H-Index: 26
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Background The optimal approach to assess right ventricular (RV) function in patients with acute symptomatic pulmonary embolism (PE) lacks clarity. Methods This study aimed to evaluate the optimal approach to assess RV function in normotensive patients with acute symptomatic PE. Outcomes assessed through 30-days after the diagnosis of PE included all-cause mortality and complicated course. Results Eight hundred forty-eight patients were enrolled. Multidetector computed tomography (MDCT) and tran...
#1P. L. den Exter (LUMC: Leiden University Medical Center)H-Index: 15
#2Wendy Zondag (LUMC: Leiden University Medical Center)H-Index: 8
Last. Menno V. HuismanH-Index: 86
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Rationale: Outpatient treatment of pulmonary embolism (PE) may lead to improved patient satisfaction and reduced healthcare costs. However, trials to assess its safety and the optimal method for patient selection are scarce.Objectives: To validate the utility and safety of selecting patients with PE for outpatient treatment by the Hestia criteria and to compare the safety of the Hestia criteria alone with the Hestia criteria combined with N-terminal pro鈥揵rain natriuretic peptide (NT-proBNP) test...
Background: The performance of different diagnostic strategies for pulmonary embolism (PE) in patient subgroups is unclear. Purpose: To evaluate and compare the efficiency and safety of the Wells rule with fixed or age-adjusted D-dimer testing overall and in inpatients and persons with cancer, chronic obstructive pulmonary disease, previous venous thromboembolism, delayed presentation, and age 75 years or older. Data Sources: MEDLINE and EMBASE from 1 January 1988 to 13 February 2016. Study Sele...
#1Jeffrey A. Kline (IU: Indiana University)H-Index: 14
#2Zachary P. Kahler (IU: Indiana University)H-Index: 5
Last. Daren M. Beam (IU: Indiana University)H-Index: 11
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Background Oral monotherapy anticoagulation has facilitated home treatment of venous thromboembolism (VTE) in outpatients.
#1Stefano BarcoH-Index: 23
#2Mareike Lankeit (University of Mainz)H-Index: 37
Last. Stavros Konstantinides (DUTH: Democritus University of Thrace)H-Index: 77
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Pulmonary embolism (PE) is a potentially life-threatening acute cardiovascular syndrome. However, more than 95鈥% of patients are haemodynamically stable at presentation, and among them are patients at truly low risk who may qualify for immediate or early discharge. The Home Treatment of Pulmonary Embolism (HoT-PE) study is a prospective international multicentre single-arm phase 4 management (cohort) trial aiming to determine whether home treatment of acute low-risk PE with the oral factor Xa in...
#1Jonne J. Sikkens (VU: VU University Amsterdam)H-Index: 7
#2Djoeke G. Beekman (VU: VU University Amsterdam)H-Index: 1
Last. Yvo M. Smulders (VU: VU University Amsterdam)H-Index: 42
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Ruling out disease often requires expensive or potentially harmful confirmation testing. For such testing, a less invasive triage test is often used. Intuitively, few negative confirmatory tests suggest success of this approach. However, if negative confirmation tests become too rare, too many disease cases could have been missed. It is therefore important to know how many negative tests are needed to safely exclude a diagnosis. We quantified this relationship using Bayes鈥 theorem, and applied t...
#1Adam L. Sharp (KP: Kaiser Permanente)H-Index: 15
#2David R. Vinson (KP: Kaiser Permanente)H-Index: 30
Last. Michael K. Gould (KP: Kaiser Permanente)H-Index: 68
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Study objective We determine the accuracy of an age-adjusted D-dimer threshold to detect pulmonary embolism in emergency department (ED) patients older than 50 years and describe current ED practices when evaluating possible pulmonary embolism. Methods This was a retrospective study of ED encounters for suspected pulmonary embolism from 2008 to 2013. We used structured data to calculate the sensitivity, specificity, negative predictive value, and positive predictive value of different D-dimer th...
#1Julio Flores (University of Alcal谩)H-Index: 6
#2Jaime Garc铆a de Tena (University of Alcal谩)H-Index: 8
Last. Ignacio Arribas (University of Alcal谩)H-Index: 7
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Age-adjusted D-dimer (AADD) appears to increase the proportion of patients in whom pulmonary embolism (PE) can safely be excluded compared with conventional D-dimer (CDD), according to a limited number of studies. The aim if this study was to assess whether the use of an AADD might safely increase the clinical usefulness of CDD for the diagnosis of PE in our setting. Three hundred and sixty two consecutive outpatients with clinically suspected PE in whom plasma samples were obtained to measure D...
Background Despite advances in hospital management in recent years, it is not clear whether mortality after acute pulmonary embolism (PE) has decreased over time. Objectives This study describes the trends in the management and outcomes of acute symptomatic PE. Methods We identified adults with acute PE enrolled in the registry between 2001 and 2013. We assessed temporal trends in length of hospital stay and use of pharmacological and interventional therapies. Using multivariable regression, we ...
Cited By30
#1Drew A. Long (William Beaumont Army Medical Center)
#2Samuel M. Keim (UA: University of Arizona)H-Index: 22
Last. Felix Ankel (UMN: University of Minnesota)H-Index: 16
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Abstract null null Background: Aortic dissection (AD) is a challenging diagnosis associated with severe mortality. However, acute AD is a rare clinical entity and can be overevaluated in the emergency department. D-dimer, both alone and in combination with the Aortic Dissection Detection Risk Score (ADD-RS), has been studied as a tool to evaluate for AD. Clinical Question: Can a negative D-dimer in low-risk patients exclude AD in the emergency department? Evidence Review: Retrieved studies inclu...
#1Joseph Bledsoe (Stanford University)H-Index: 14
#2Christopher Kelly (UofU: University of Utah)H-Index: 2
Last. C. Gregory Elliott (Intermountain Medical Center)H-Index: 48
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Objective Multiple professional societies recommend pre-test probability (PTP) assessment prior to imaging in the evaluation of patients with suspected pulmonary embolism (PE), however, PTP testing remains uncommon, with imaging occurring frequently and rates of confirmed PE remaining low. The goal of this study was to assess the impact of a clinical decision support tool embedded into the electronic health record to improve the diagnostic yield of computerized tomography pulmonary angiography (...
#1Jatin Narang (Cleveland Clinic Lerner College of Medicine)H-Index: 3
#2Amy S. Nowacki (Cleveland Clinic Lerner College of Medicine)H-Index: 25
Last. Sharon E. Mace (Cleveland Clinic Lerner College of Medicine)H-Index: 20
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Abstract Objectives Determine whether D-dimer concentration in the absence of imaging can differentiate patients that require anti-coagulation from patients who do not require anti-coagulation. Methods Data was obtained retrospectively from 366 hemodynamically stable adult ED patients with suspected pulmonary embolism (PE). Patients were categorized by largest occluded artery and aggregated into: 鈥楻equire anti-coagulation鈥 (main, lobar, and segmental PE), 鈥楧oes not require anti-coagulation鈥 (sub...
#1Vitali Koch (Heidelberg University)H-Index: 1
#2Moritz Biener (Heidelberg University)H-Index: 16
Last. Evangelos Giannitsis (Heidelberg University)H-Index: 70
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BACKGROUND: D-dimer is elevated in a variety of conditions. The purpose of this study was to assess the positive predictive value of D-dimer to rule in patients with confirmed pulmonary embolism, deep vein thrombosis, acute aortic dissection or thrombosis of the upper extremity in comparison to patients with elevated D-dimer for other reasons. METHODS AND RESULTS: We studied 1334 patients presenting to the emergency department with pulmonary embolism (n=193), deep vein thrombosis (n=73), acute a...
A healthy, active woman in her 70s reported intermittent exertional dyspnoea for 2 months, notable during frequent open-water swimming. Symptoms were similar to an episode of travel-provoked pulmonary embolism 3 years prior. She denied chest pain, cough, fever, extremity complaints and symptoms at rest. Due to the COVID-19 pandemic, her healthcare system was using secure telemedicine to evaluate non-critical complaints. During the initial video visit, she appeared well, conversing normally witho...
#1Lisa Fetters (UM: University of Michigan)
#2Sue Sirianni (Sinai Grace Hospital)
INTRODUCTION Heparin resistance was discovered in a patient in the surgical intensive care unit who underwent emergency endovascular coiling and later an anterior communicating artery clipping procedure to treat subarachnoid hemorrhage due to rupture of an anterior communicating artery aneurysm. CLINICAL FINDINGS On intensive care unit day 17/postoperative day 3, the patient experienced shortness of breath, persistent tachycardia, and hypoxia. Bilateral pulmonary emboli, a saddle embolus, and lo...
#1William B. Stubblefield (VUMC: Vanderbilt University Medical Center)H-Index: 5
#2Jeffrey A. Kline (IU: Indiana University)H-Index: 78
Venous thromboembolism (VTE) includes the diagnosis of either deep venous thrombosis (DVT) and/or pulmonary embolism (PE). Venous thromboembolism is a major healthcare burden world-wide with an increasing incidence in both Europe and the United States over the last two decades. The majority of patients diagnosed with VTE in the acute care setting are at low risk for an adverse event. Outpatient treatment for patients deemed low-risk by validated clinical decision tools leads to safe, efficacious...
#1Lauren M. Westafer (UMMS: University of Massachusetts Medical School)H-Index: 7
#2Meng-Shiou Shieh (UMMS: University of Massachusetts Medical School)H-Index: 12
Last. Peter K. Lindenauer (UMMS: University of Massachusetts Medical School)H-Index: 62
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Objective While guidelines recommend outpatient management of patients with low-risk pulmonary embolism (PE), little is known about the disposition of patients with PE diagnosed in United States emergency departments (EDs). We sought to determine disposition practices and subsequent health care utilization in patients with acute PE in U.S. EDs. Methods This was a retrospective cohort study of adult ED patients with a new diagnosis of acute PE treated at 740 U.S. acute care hospitals from July 1,...
#1Jeffrey Dubin (Georgetown University)H-Index: 1
#2Mary Kathleen Ratay (MedStar Washington Hospital Center)
Last. Munish Goyal (Georgetown University)H-Index: 22
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Abstract Background Several previous studies have investigated the clinical utility of age-adjusted D-dimer cutoffs for diagnosing pulmonary embolism (PE). Objectives We performed a pre/post implementation study, using data from a mid-Atlantic healthcare system comprising 6 hospitals and 400,000 ED visits to determine whether implementing age adjusted D-dimer cutoffs reduced the number of imaging tests performed. Methods Retrospective study of all patients who had a D-dimer performed during ED v...
#1Angela F. Jarman (UC Davis: University of California, Davis)H-Index: 4
#2Bryn E. Mumma (UC Davis: University of California, Davis)H-Index: 11
Last. Brandon C. Maughan (OHSU: Oregon Health & Science University)H-Index: 3
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Acute pulmonary embolism (PE) affects over 600,000 Americans per year and is a common diagnostic consideration among emergency department patients. Although there are well-documented differences in the diagnosis, treatment, and outcomes of cardiovascular conditions, such as ischemic heart disease and stroke, the influence of sex and gender on PE remains poorly understood. The overall age-adjusted incidence of PE is similar in women and men, but women have higher relative rates of PE during early...
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