Accurate Diagnosis Of Pulmonary Embolism Research Articles

Kanserli hastalarda kan D-dimer değerlerinin pulmoner emboli tanısını öngörmedeki önemi

Aim: Cancer patients have increased risk of thrombosis. However, the use of D-dimer as a biomarker in malignancies, major surgery, infections and pregnancy was not recommended since D-dimer values were detected in high levels without PE. In this study, we aimed to evaluate the D-dimer values for the selected group of patients in the light of their clinical and demographic data and to reveal the utility of blood D-dimer measurements in cancer patients as a clinical decision rule. Also we aimed to define a new cut- off value for cancer patients who accurately diagnosed as pulmonary embolism.Material and Method: This single -center retrospective and cross-sectional study was based upon patients’ medical reports. The D-dimer values above 500 mcg/dl (>500 mcg/dl ) were considered as positive results.Results: One hundred twenty-eight patients (44 cancer patients (the case), 84 without cancer history (the control)) with accurate diagnosis of pulmonary embolism were included in the study. The mean blood level of D-dimer in the control group was 1729.3±2272.5 mcg/dl while the same parameters were calculated as 3326.9±3162.2 mcg/dl in the group with history of cancer indicating that the presence of malignancy caused a higher level of D-dimer levels. The most appropriate cut-off value in cancer patients was found as 1205 mcg /dl which had the sensitivity of 74%, specifity of 64%. This value corresponded to 2.41 times of the upper limits of the D-dimer value according to our laboratory results.Conclusion: For the diagnosis of PE the blood D-dimer values were absolutely a useful and a valuable parameter in cancer patients. We obtained a different cut-off value for D-Dimer in cancer patients which we think that will probably be a guidance for the future perspective of clinicians.

Diagnostic Accuracy of Age-Adjusted D-Dimer Cutoff in Suspected Cases of Pulmonary Embolism

IntroductionCurrent guidelines recommend use of clinical pretest probability scores, d-dimer assay, and imaging studies in the diagnosis of pulmonary embolism (PE). Studies have shown that normal d-dimer levels with low-intermediate probability in Wells score can safely exclude PE in most cases. Usually, d-dimer level of less than 500 µg/L is used to decide that no further imaging studies such as computed tomography pulmonary angiography (CTPA) or ventilation perfusion (V/Q) scan) are required. However, the conventional cutoff of 500 µg/L may not be as specific in all patients as d-dimer levels increase with age. Thus, use of age-adjusted d-dimer cutoff has been advocated which is defined as (age × 10) µg/L in patients 50 years or older.ObjectiveTo study if age-adjusted d-dimer is helpful in decreasing imaging studies without missing the diagnosis of PE in suspected cases.MethodsWe did an observational retrospective study of all consecutive adult patients who presented to the emergency department from January 2014 to December 2016. The patients who were clinically suspected with PE and underwent subsequent workup along with d-dimer assays were included for analysis. The number of imaging studies performed for PE diagnosis were recorded.ResultsWe included 3,197 patients in the study. Median age was 55 years, and 67% were females (Table 1). Total 2,937 (92%) patients had elevated d-dimer levels based on conventional d-dimer cutoff compared to 2,526 (79%) patients based on age-adjusted d-dimer cutoff. The age-adjusted d-dimer cutoff was more specific (21% vs 8%, p-value<0.0001) but less sensitive (100% vs 95%, p-value= 0.15) than conventional cutoff (Table 2). The use of age-adjusted d-dimer cutoff would have avoided 409 (13% of total) imaging studies (Table 3). However, 2 cases (0.7% of total) with PE, which would have underwent imaging study with conventional cutoff, would have been missed with age-adjusted d-dimer cutoff. The Wells score was 3, intermediate pretest probability, for both cases of PE.ConclusionAge-adjusted d-dimer cutoff can significantly decrease the number of imaging studies performed in cases of suspected PE. However, as shown in our study, there is a chance of missing cases with actual PE. Thus, clinicians should always be aware of a rare probability of false negative result with age-adjusted d-dimer levels. Further stratification of the probability risk or the prompt use of imaging studies in cases with higher clinical suspicion can help in accurate diagnosis of PE. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Reliability of on-call radiology residents’ interpretation of 64-slice CT pulmonary angiography for the detection of pulmonary embolism

Computed tomography (CT) angiography for pulmonary embolism (PE) is the present standard for diagnosing PE. In many teaching hospitals, radiology residents are the first to review the case and to make an initial interpretation of the images. Accurate diagnosis of PE is crucial, especially in the emergency care setting. To evaluate the discrepancies between resident and staff interpretations of 64-slice CT angiogram for PE. Discrepancies between the preliminary reports by the on-call radiology resident were compared to the final report by the staff radiologist in 215 consecutive cases of 64-slice CT angiogram performed for PE, from May 2005 to March 2008. Discrepancies were noted in 25 of the 215 studies (11.6%). These residents' discrepancies consisted of three false-positive, four false-negative, and 18 equivocal cases. There was a decrease in the discrepancy rate from the second year to the fifth year of training by approximately 60%. The rate of discrepancy fell steeply between the second and fifth year of the residents training from 18.5% to 6.9%. Our study suggests that it is reasonable to have on-call radiology residents perform the preliminary interpretations of 64-slice CT for PE studies.

Hemodynamic indexes derived from computed tomography angiography to predict pulmonary embolism related mortality.

Pulmonary embolism (PE) induces an acute increase in the right ventricle afterload that can lead to right-ventricular dysfunction (RVD) and eventually to circulatory collapse. Hemodynamic status and presence of RVD are important determinants of adverse outcomes in acute PE. Technologic progress allows computed tomography angiography (CTA) to give more information than accurate diagnosis of PE. It may also provide an insight into hemodynamics and right-ventricular function. Proximal localization of emboli, reflux of contrast medium to the hepatic veins, and right-to-left short-axis ventricular diameter ratio seem to be the most relevant CTA predictors of 30-day mortality. These elements require little postprocessing time, an advantage in the emergency room. We herein review the prognostic value of RVD and other CTA mortality predictors for patients with acute PE.

The Challenge of Diagnosing Pulmonary Embolism in Children, Pregnant Women, and Elderly Patients: A Descriptive Review of the Literature

The prompt and accurate diagnosis of pulmonary embolism (PE) greatly influences patient outcomes. However, diagnosing PE is one of the most difficult challenges confronting physicians, even more so when the clinical suspicion is addressed in children, during pregnancy, or in elderly patients. In these patient groups, symptoms and signs from concomitant conditions or diseases may mimic PE and make difficult defining clinical probability categories for PE as usually applied to general adult patients. Moreover, the diagnostic techniques show wider, specific limitations in these settings. PE is considered rare in children. The diagnostic management of a child with suspected PE is largely extrapolated from the knowledge achieved in adult patients. An increased risk of venous thromboembolism is reported in all trimesters of pregnancy and in the puerperium. An accurate diagnosis of PE in pregnancy has important implications, including the need for prolonged anticoagulation, delivery planning, and prophylaxis during future pregnancies, as well as concerns about future oral contraceptive use and estrogen therapy. Although incidence, morbidity, and mortality increase steadily with age, PE remains an underdiagnosed disease in elderly patients. About 40% of PE found at necropsy were not suspected antemortem. In the present article, challenges in diagnosing PE in children, during pregnancy, and in the elderly will be discussed, reviewing the available clinical, laboratory, and instrumental diagnostic strategies.

Withholding anticoagulation after a negative computed tomography pulmonary angiogram as a stand‐alone imaging investigation: a prospective management study

Accurate diagnosis of pulmonary embolism (PE) is essential and it is not clear whether a computed tomography pulmonary angiogram (CTPA) could be used as a stand-alone imaging investigation. The aim of the study was to test the accuracy of the clinical outcome of a negative CTPA as a stand-alone imaging investigation to exclude PE. Five hundred and thirty-four consecutive patients who had a CTPA for diagnosis or exclusion of PE were recruited from March 2003 to October 2004. Four hundred and ninety-four patients had a helical CTPA as a stand-alone imaging investigation for diagnosis or exclusion of PE. A 3-month post-CTPA follow up was carried out in all patients to establish the clinical outcome accuracy of a negative CTPA as a stand-alone imaging investigation. There were 387 (78.3%) negative and 107 (21.7%) positive CTPA examinations. The average age of the patients was 57.16 years (standard deviation 18.57). Among those with a negative CTPA who survived, one patient had deep vein thrombosis and 342 patients had no evidence of an episode of venous thromboembolism or PE at the 3-month follow up. Thirty-eight patients died within the 3-month follow-up period and one patient's death was attributed to suspected PE. The negative predictive value of a CTPA is 99.5% (95% confidence interval 98.1-99.9%). Helical negative CTPA examination excludes clinically significant PE as a stand-alone imaging investigation. Where concurrent deep vein thrombosis is suspected, lower limb needs to be imaged by ultrasound if the CTPA is negative.

Multislice Computed Tomography for Pulmonary Embolism — A Technological Marvel

Rapid and accurate diagnosis of pulmonary embolism will improve survival and quality of life because treatment decreases mortality and the likelihood that thromboembolic pulmonary hypertension or t...

The Diagnostic Evaluation of Pulmonary Embolism

Due to the morbidity and mortality associated with either untreated disease or inappropriate anticoagulant therapy, accurate diagnosis of pulmonary embolism is essential. Pulmonary angiography, the current gold standard test for diagnosing pulmonary embolus, is both invasive and costly; therefore, noninvasive diagnostic strategies have been developed. Noninvasive tests often have to be combined to either raise the posttest probability of disease to a level justifying treatment or lower it to a level at which withholding treatment is warranted. Diagnostic algorithms involving clinical assessment; venous ultrasonography; D-dimer testing; ventilation-perfusion lung scanning; and, more recently, computed tomography have been validated in management trials of patients with a suspected pulmonary embolism. The optimal strategy at individual institutions is dependent on local availability, expertise, and cost. Magnetic resonance imaging and combined computed tomographic pulmonary angiography and venography possess the potential to be used as stand-alone tests for pulmonary embolism but require further evaluation.

False positive perfusion lung scintiscans in tetraplegic patients: A case series

An accurate diagnosis of pulmonary embolism is essential to prevent excessive morbidity and mortality from either inappropriate therapy or failure to institute anticoagulation. The diagnosis of pulmonary embolism in tetraplegic spinal cord injury patients is complicated by frequent inability to perform the ventilation portion of the ventilation-perfusion scintiscan (V/Q scan) and by controversy regarding classification of defects on perfusion-only scans, as well as by coexisting pulmonary disease, systemic illness, related injuries, and the tendency for tetraplegic patients to have unexplained fever. This report describes three tetraplegic ventilator-dependent patients with hypoxic respiratory failure and normal chest radiographs who had large defects on perfusion-only lung scans. Ventilation scintiscans were not performed because the patients were ventilator-dependent with tracheostomies. Pulmonary angiography findings were normal in all patients, and all three responded to aggressive pulmonary toilet. Even large defects on perfusion-only scans despite normal chest radiographs should not be used to establish a diagnosis of pulmonary embolism in tetraplegic patients, and further diagnostic imaging is warranted.

Transesophageal echocardiography in monitoring of intrapulmonary embolism during inferior vena cava tumor resection

T HE EFFECTIVE management of intraoperative pulmonary embolism depends on its early recognition and the type of embolic material.l,2 Early detection of embolism can be achieved by transesophageal echocardiography (TEE)) Surgery for the removal of renal cell carcinoma extending into the inferior vena cava (IVC) and right atrium has been associated with pulmonary emholization. 4 In an attempt to prevent tumor embolization, intraoperative delineation of the tumor extension into the IVC with TEE has been advocated as an adjunct to the surgical technique. 5 In the present report, two patients are described who underwent resections of renal tumor with extension into the IVC and had pulmonary emboli. Although TEE represents a sensitive diagnostic tool for the detection of pulmonary embolism, in both patients, the embolism could not be visualized with TEE after it reached the peripheral pulmonary circulation. This indicates that for the accurate diagnosis of pulmonary embolism, continuous and uninterrupted TEE monitoring may be required because, once the embolus reaches the peripheral segments of the pulmonary circulation, diagnosis can be established either only clinically or based on indirect TEE signs.

Assessment of pulmonary embolism.

Multicenter studies have shown with increasing evidence that thrombolytic therapy is effective in the treatment of acute massive pulmonary embolism. Controlled [1, 2] and uncontrolled studies [3-5] have shown the effectiveness of the plasminogen activator (t-PA), which was confirmed by other studies [6]. Also, a large European cooperative study showed the effectiveness of t-PA with the improvement of angiographic and hemodynamic variables compared to heparin [7]. Current therapy seems to improve patients' prognosis. Thus, a rapid and accurate diagnosis of pulmonary embolism is important. But previous calculations of mortality in patients with pulmonary embolism still show a rate of 24% with no decrease in that rate between 1979 and 1985. According to Goldhaber [8], these data indicate that pulmonary embolism is frequently fatal, despite the increased use of lung scanning and pulmonary angiography to establish the diagnosis of pulmonary embolism.

The significance of venography in the management of patients with clinically suspected pulmonary embolism

The accurate diagnosis of pulmonary embolism causes many problems. Clinical signs are non-specific, and ventilation-perfusion lung scanning has high sensitivity but variable specificity. In more than 90% of cases a pulmonary embolus is derived from deep venous thrombosis in the lower extremities. We have performed a prospective study to evaluate venography in the management of patients with suspected pulmonary embolism. A total of 169 patients were included in the study, and a ventilation-perfusion scan was performed in all cases. Forty-four (26%) patients had a normal scan and treatment was not given (group A). The other 125 (74%) patients, who had an abnormal scan, underwent bilateral venography. Venous thrombosis was demonstrated in 63 patients, and they were treated with oral anticoagulants for 3 months (group B). The remaining 62 patients, who showed no venous thrombosis, did not receive anticoagulant therapy (group C). During follow-up, 1 patient in group A, 3 patients in group B and 1 patient in group C developed a new deep venous thrombosis. One patient in group B suffered a pulmonary embolus. It is concluded that venography of the lower extremities can be of additional value in the management of patients with pulmonary embolism when the lung scan does not provide sufficient information.

Diagnosis of Pulmonary Embolism

An accurate diagnosis of pulmonary embolism is essential to prevent excessive morbidity and mortality from lack of therapy or inappropriate anticoagulation. Clinical signs and symptoms are reported to be nonspecific, although published studies do not allow calculation of true specificity. Since certain clinical characteristics or groups of findings may be sensitive enough for pulmonary embolism, the diagnosis is unlikely in their absence. Ventilation-perfusion lung scanning has high sensitivity but variable specificity for pulmonary embolism. Patients with scans showing multiple segmental or lobar perfusion defects with normal ventilation have a high probability of pulmonary embolism. Scans with less extensive perfusion abnormalities or matching ventilation defects do not reliably exclude pulmonary embolism. Pulmonary angiography is the most definitive procedure for diagnosing pulmonary embolism. Digital subtraction pulmonary angiography and radiolabeled platelet scanning are promising but require more extensive validation before routine use.

Current status of ventilation-perfusion imaging

The major clinical use of ventilation-perfusion (V/Q) scintigraphy is for the diagnosis of pulmonary embolism (PE). Accurate diagnosis of PE is essential since effective treatment is available but involves some risk to the patient. The scintigraphic characteristics of PE are segmental perfusion defects in lung that is normally ventilated and normal on the radiograph. The inherent shortcoming of perfusion scintigraphy is its lack of specificity. Combining a ventilation study with perfusion imaging improves the diagnostic specificity of lung scintigraphy. Xenon-133 is currently the most commonly used radionuclide for routine ventilation studies; a long washout technique is more sensitive than single-breath imaging when this radionuclide is used. We obtain preperfusion xenon-133 ventilation studies with a 4-min rebreathing equilibrium phase and a long 5-min washout phase to obtain maximum information. It is imperative that V/Q studies be interpreted with a current high quality chest radiograph. Interpretation of V/Q studies for PE is perhaps best done by assigning a probability diagnosis, since rarely is absolute specificity possible. This article details the criteria we use for these probability determinations.