Definitive Diagnosis Of Pulmonary Embolism Research Articles

Evaluation of Hemogram Parameters in the Diagnosis of Pulmonary Embolism: Immature Granulocytes and Other New Tips.

Pulmonary embolism (PE) is an important cause of sudden death and is difficult to diagnose. Therefore unnecessary radiological investigations are often resorted to. Although some inflammatory parameters in the hemogram have been found to play a role in the diagnosis of PE, many parameters have not been adequately investigated. We aimed to evaluate potential inflammatory parameters in hemogram in the diagnosis of PE and to determine the parameters with the highest diagnostic value. This single-center, retrospective study was performed by evaluating 114 cases with suspected PE admitted to the emergency department between January 2017 and June 2022. Among 114 cases, 62 cases with a definitive diagnosis of PE by pulmonary computed tomography angiography served as the PE group and 52 cases without PE served as the control group. Admission hemogram parameters of both groups were recorded. Potential chronic diseases and acute conditions affecting hemogram were excluded from the study. In the multivariate model; immature granulocyte (IG), neutrophil/lymphocyte ratio (NLR), monocyte % and platelet large cell ratio (P-LCR) were found to be significantly and independently effective in differentiating cases with and without PE (P˂.05). Our findings suggest that high IG, high NLR, high monocyte %, and low P-LCR values have diagnostic value in cases with suspected PE. However the usability of IGs in the diagnosis of PE is a new finding. Hemogram is cheap, easily accessible, and potential inflammatory biomarkers in hemograms may increase physicians' awareness in the diagnosis of PE.

Pulmonary artery obstruction index, pulmonary artery diameter and right ventricle strain as prognostic CT findings in patient with acute pulmonary embolism

ObjectiveThis study was designed to determine predictors of pulmonary hypertension and signs of right heart dysfunction caused by pulmonary embolism (PE) that may lead to early detection of high-risk patients. So the predictive value of pulmonary artery obstruction index (PAOI), measured by pulmonary CT angiography (PCTA) in the acute setting, in predicting the patients susceptible to PE cardiac complications was evaluated. Also two other PCTA indices, pulmonary artery diameter (PAD), and right ventricle (RV) strain, in these patients were investigated and their predictive value for cardiac complications on follow up echocardiography were demonstrated. Materials and methodsIn the study 120 patients with a definite diagnosis of PE were included. The PAOI, PAD and RV strain were measured using PCTA at the time of the initial diagnosis. Transthoracic echocardiography was done 6 months after the diagnosis of PE and RV echocardiographic indices were measured. Pearson correlation was used to investigate correlation between PAOI, PAD, RV strain and signs of right heart dysfunction. ResultsPAOI was strongly correlated with systolic pulmonary artery pressure (SPAP) (r=0.83), RV systolic pressure (r=0.78) and RV wall thickness (r=0.61) in long-term follow up echocardiography. A higher rate of RV dysfunction and RV dilation was detected among the patients with higher PAOI (P<0.001). PAOI≥18 was strongly predictive for development of RV dysfunction. Also developments of pulmonary hypertension, RV systolic hypertension, RV dilation, RV dysfunction, and RV hypertrophy were significantly more common among patients with higher PAD and RV strain (P<0.001). ConclusionsPAOI, PAD and RV strain are sensitive and specific PCTA indices that can predict the development of long-term complications such as pulmonary hypertension and right heart dysfunction, at the time of initial PE diagnosis.

Índice de obstrucción de la arteria pulmonar, diámetro de la arteria pulmonar y strain del ventrículo derecho como hallazgos pronósticos de la tomografía computarizada en el paciente con embolia pulmonar aguda

ObjectiveThis study was designed to determine predictors of pulmonary hypertension and signs of right heart dysfunction caused by pulmonary embolism (PE) that may lead to early detection of high-risk patients. So the predictive value of pulmonary artery obstruction index (PAOI), measured by pulmonary CT angiography (PCTA) in the acute setting, in predicting the patients susceptible to PE cardiac complications was evaluated. Also two other PCTA indices, pulmonary artery diameter (PAD), and right ventricle (RV) strain, in these patients were investigated and their predictive value for cardiac complications on follow up echocardiography were demonstrated. Materials and methodsIn the study 120 patients with a definite diagnosis of PE were included. The PAOI, PAD and RV strain were measured using PCTA at the time of the initial diagnosis. Transthoracic echocardiography was done 6 months after the diagnosis of PE and RV echocardiographic indices were measured. Pearson correlation was used to investigate correlation between PAOI, PAD, RV strain and signs of right heart dysfunction. ResultsPAOI was strongly correlated with systolic pulmonary artery pressure (SPAP) (r=0.83), RV systolic pressure (r=0.78) and RV wall thickness (r=0.61) in long-term follow up echocardiography. A higher rate of RV dysfunction and RV dilation was detected among the patients with higher PAOI (P<0.001). PAOI≥18 was strongly predictive for development of RV dysfunction. Also developments of pulmonary hypertension, RV systolic hypertension, RV dilation, RV dysfunction, and RV hypertrophy were significantly more common among patients with higher PAD and RV strain (P<0.001). ConclusionsPAOI, PAD and RV strain are sensitive and specific PCTA indices that can predict the development of long-term complications such as pulmonary hypertension and right heart dysfunction, at the time of initial PE diagnosis.

Diagnostic Role of Mean-Platelet Volume in Acute Pulmonary Embolism: A Meta-analysis and Systematic Review.

Background:Acute pulmonary embolism (PE) is the third most fatal cardiovascular disease. PE is frequently misdiagnosed due to its clinical presentation’s heterogeneity and the inexistence of biomarkers for its immediate diagnosis. Mean platelet volume (MPV) has shown a potential role as a biomarker in acute PE. In this analysis, we aimed to systematically compare the MPV in patients with and without definite diagnosis of PE, in emergency departments.Methods:Embase, PubMed and Medline were searched for relevant publications, in English. The main inclusion criteria were studies which compared MPV in patients with acute PEA versus a control group.Results:Thirteen studies consisting of a total number of 2428 participants were included. Of the participants included, 1316 were patients with confirmed acute PE, and 1112 were assigned to the control group. MPV was significantly higher in patients with acute PE than in controls (RR: 0.84, 95% CI: 0.76 – 0.92; P < .00001). There was a significant heterogeneity in the data.Conclusions:This analysis showed higher MPV to be associated with acute PE immediate diagnosis. These data show promise for the use of MPV as a readily available biomarker for the diagnosis of acute PE at the emergency department.

Early diagnosis of pulmonary embolism in patients with skin and soft tissue defects after trauma

Objective: To investigate the early diagnosis method of pulmonary embolism in patients with skin and soft tissue defects after trauma. Methods: From January 2011 to July 2014, 5 patients with skin and soft tissue defects and pulmonary embolism after trauma were admitted to Department of Plastic Surgery and Burns of the Affiliated Drum Tower Hospital of Nanjing University Medical School, including 4 males and 1 female, aged 26-68 years. The medical records of the 5 patients were retrospectively analyzed. Hierarchical screening of patients with suspected pulmonary embolism was performed after admission for 4-45 days. Computed tomography pulmonary angiography (CTPA) was performed immediately in 2 patients who had hemodynamic disorder and were able to tolerate CTPA, and pulmonary embolism was confirmed. Clinical risk assessment was conducted for the other 3 patients who had no obvious hemodynamic disorder and only had clinical manifestations of pulmonary embolism such as chest tightness and dyspnea. Among the 3 patients, two of them were assessed as high risk possibility by clinical risk assessment and diagnosed with pulmonary embolism by CTPA immediately. The other one patient's clinical risk assessment was moderate risk possibility, but D-dimer was positive, and the patient was diagnosed with pulmonary embolism by CTPA immediately. Wound exudation of all patients was collected within 1 week after admission for microbial culture, and wound debridement and skin grafting were performed according to the wound condition. The color Doppler ultrasonography of blood vessel on lower extremity was performed to determine deep venous thrombosis of lower extremity after appearance of symptoms of pulmonary embolism. The patient was immediately given urokinase or recombinant tissue plasminogen activator by intravenous infusion for thrombolysis after definite diagnosis of pulmonary embolism. The activated partial thromboplastin time (APTT) was monitored after treatment, and standardized anticoagulation began when APTT was equal to or lower than 70 seconds. The treatment results of patients, D-dimer measurement value, bed time before definite diagnosis of pulmonary embolism, number of patients underwent wound debridement during hospitalization, definite diagnosis time of pulmonary embolism after wound debridement, and number of patients with deep venous thrombosis of lower extremity and wound infection were recorded. Results: Wounds with skin and soft tissue defects of all patients were completely healed, all skin grafts survived well, pulmonary embolism recovered well after timely treatment, and the trunk and branches of involved pulmonary artery recovered blood supply. The course of disease ranged from 1 month to 3 months. The measurement value of D-dimer was 2.4-31.7 mg/L, and the measurement values of D-dimer of 4 patients were equal to or higher than 5.0 mg/L. The bed time before definite diagnosis of pulmonary embolism was 4-46 days, with an average of 23.2 days. Four patients underwent wound debridement during hospitalization. The definite diagnosis time of pulmonary embolism after the wound debridement was 14-40 days, with an average of 20.5 days. Four patients were diagnosed with deep venous thrombosis of lower extremity. All patients had wound infection, and the bacteria causing wound infection included Pseudomonas aeruginosa of 2 cases, Staphylococcus aureus of 2 cases, and Enterococcus faecalis of 1 case. Conclusions: In the diagnosis process of pulmonary embolism in patients with skin and soft tissue defects after trauma, D-dimer positive, long-term bed rest, experiencing operation during hospitalization, and with deep vein thrombosis and wound infection can be regarded as the key points for diagnosis. When a patient has clinical symptoms of pulmonary embolism and the above conditions, the clinician should promptly perform hierarchical screening, select the corresponding examination to confirm pulmonary embolism, and immediately perform thrombolysis for the patient with pulmonary embolism according to the patient's tolerance, thereby improving patient survival rate.

Correlation between the Wells score and the Quanadli index in patients with pulmonary embolism.

Determining clinical probability of pulmonary embolism (PE) with Wells scoring system is the first step towards diagnosis of PE. Definitive diagnosis of PE is confirmed by computed tomography pulmonary angiography (CTPA). This was a prospective study on 80 patients referred to the Institute for Pulmonary Diseases of Vojvodina with suspected PE between April 2010 and August 2012. Clinical probability of PE was determined according to the Wells and modified Wells scoring system. CTPA was performed in 60 patients. The degree of pulmonary vascular obstruction was quantified by the Qanadli index. Low clinical probability of PE was present in one patient (1.6%), moderate in 43 (71.6%) and high in 16 (26.6%) patients. PE was confirmed in 50 (83.3%) patients. There were 21 patients (42%) whose Quanadli index was <25%, 18 (36%) between 25%-50%, while Quanadli index was ≥50 in 11 patients (22%). When compared to CTPA findings, modified Wells scoring system showed 90% sensitivity [95% confidence interval (CI) 78.2%-96.6%], and 20% specificity (95% CI 3.11%-55.6%), positive predictive value (PPV) 84.9% (95% CI 72.4%-93.2%) and negative predictive value (NPV) 28.6% (95% CI 4.5%-70.7%). There was weak positive correlation between Wells score and Quanadli index (r = 0.14; P = 0.29), without statistical significance. Wells score was significantly higher in haemodynamically unstable than in haemodynamically stable patients (6.8 vs 5.6, P = 0.014). There was no statistically significant difference between the values of Quanadli index in these two groups (31.33% vs 26.64%, P = 0.062). Modified Wells criteria have high sensitivity but low specificity in PE diagnostics. The Wells score does not correlate well with the Quanadli index.

A Young Man Presenting with Pleuritic Chest Pain and Fever after Electrophysiological Study and Implantable Cardioverter-Defibrillator Placement: Diagnostic Difficulties and Value of Bedside Thoracic Sonography.

We describe the case of a 23-year-old man presenting with recurrent pleuritic chest pain and prolonged fever after electrophysiology testing and placement of an implantable cardioverter-defibrillator because of a suspected arrhythmogenic right ventricular dysplasia. The clinical suspicion was initially directed toward pneumonia with pleural effusion and later toward an infection of the cardiac device complicated by septic pulmonary embolism. The definitive diagnosis of pulmonary embolism and infarction was suggested by a point-of-care thoracic sonography, performed at the bedside by a clinician caring for the patient, and then confirmed by contrast enhanced computed tomography, which also showed thrombosis of the left iliofemoral vein, site of percutaneous puncture for cardiac catheterization. Prolonged fever was attributable to a concomitant Epstein-Barr virus primary infection that acted as confounding factor. The present report confirms the value of bedside thoracic sonography in the diagnostic evaluation of patients with nonspecific respiratory symptoms.

Massive Pulmonary Embolism

To purchase reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 8991712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org. The patient’s hemodynamic stability provided the multidisciplinary team with an opportunity to perform diagnostic tests to look for a possible cause for the cardiac arrest. A 2dimensional echocardiogram showed dilatation of the right ventricle and moderate tricuspid regurgitation with pulmonary artery systolic pressures of 60 to 65 mm Hg, all abnormal findings in a healthy heart. This result, coupled with the postpartum arrest, led to a tentative diagnosis of pulmonary embolism. A ventilation/ perfusion scan indicated a high probability of pulmonary embolism, and a computed tomography scan of the thorax showed a saddle embolism, which confirmed the diagnosis. The definitive diagnosis of pulmonary embolism proved a great threat to the patient’s survival, and an urgent interdisciplinary team meeting ensued. Physician representatives from obstetrics, cardiology, pulmonary medicine, and cardiothoracic surgery, as well as a variety of nursing representatives who directly provided care for the patient, played a crucial part in the decisionmaking process. The critical care nurses reported decerebrate posturing of the patient after the cardiac arrest, which may be indicative of Kathleen Shaughnessy, MSN, CRNP, CCRN

Acute Right Bundle Branch Block as a Presenting Sign of Acute Pulmonary Embolism

To the Editor: Rosenberger et al. (1) described the limited utility of intraoperative transesophageal echocardiography (TEE) as a primary diagnostic tool for obtaining a definitive diagnosis of pulmonary embolism (PE). We wish to highlight the role of the electrocardiogram (ECG) in diagnosing PE. A 51-yr-old patient presented to the operating room for reduction of a hip dislocation. The patient's preoperative ECG, obtained earlier the same day, revealed sinus bradycardia (Fig. 1). Immediately before a planned induction of general anesthesia, we attached an ECG monitor and noted a new right bundle branch block (RBBB). We postponed induction and obtained a 12-lead ECG in the operating room (Fig. 2). The ECG revealed new findings, including normal sinus rhythm, (RBBB), multiple ST segment abnormalities, S1Q3T3 pattern, and T wave inversion V1-V3. A subsequent computerized tomography (CT) scan revealed multiple, deep-venous thrombi and massive PE.Figure 1.: Preoperative electrocardiogram obtained 12 hours prior to planned surgery. Sinus bradycardia.Figure 2.: Electrocardiogram obtained in the operating room. Normal sinus rhythm, right bundle branch block, multiple ST segment abnormalities, S1Q3T3 pattern, and T wave inversion V1-V3.The usefulness of ECG findings in the diagnosis of PE is controversial (1). As with clinical presentation and physical examination, an ECG is of limited value in diagnosing PE: findings are often inconsistent and nonspecific (1). ECG changes may vary with the size of the embolus, impact upon hemodynamics, and cardiopulmonary reserve (1,2). Classically described findings are often absent, or they are equally prevalent in patients suspected of having PE in whom an alternative diagnosis is ultimately made (2). Although approximately 90% of patients with PE have at least one abnormality on ECG, many of these findings are nonspecific and therefore limited in their diagnostic utility in cases of suspected PE (3). Given the widespread use of imaging modalities for diagnosis of PE, the primary function of the ECG in modern clinical practice is to raise or reinforce suspicion (4). In our case it was a new RBBB, indicative of impairment in right-sided cardiac conduction, that prompted further evaluation. Its significance for diagnosing PE is unclear. One study found new RBBB in 80% of patients with massive trunk embolism but in no cases of peripheral embolism in the pulmonary artery (4). Another study found RBBB present in 10% of patients with confirmed PE, although the severity of PE failed to correlate with the presence or absence of RBBB (5). In that same study, a pattern of subepicardial ischemia (T-wave inversions) in the precordial leads was the finding most often noted in PE and also the finding most closely correlated with severity. Inverted T-waves, however, present in many other processes, are thus of limited diagnostic utility. In another study, 28 different ECG abnormalities were analyzed in patients suspected of having PE who presented for imaging studies (2). Only tachycardia (42%) and incomplete RBBB (7%) occurred significantly more often in patients who were confirmed by imaging to indeed have PE than patients with other etiologies. In the same study complete RBBB was found in only 4% of cases of confirmed PE, and it was not diagnostic. Even the classic S1Q3T3 pattern, with a reported prevalence of 12% in massive PE, may occur frequently enough in patients falsely suspected of having PE so as to limit its usefulness as a diagnostic criterion (2,5,6). Statistical analysis is complicated by the numerous possible combinations of findings that may exist on any given ECG. Given that the ECG alone is of limited value in the diagnosis of PE, clinicians must consider the clinical presentation in its entirety (7). Typically, it is prudent to pursue confirmatory imaging studies, such as a CT scan, before proceeding with definitive treatment for PE. The article by Rosenberger et al. indicates that TEE lacks the sensitivity to play this role. The most important role of the ECG is to trigger further evaluation that can lead to definitive diagnosis and prompt treatment of this life-threatening condition. Greg Ginsburg, MD Neelakantan Sunder, MD Priscilla Grace Harrell, MD Department of Anesthesia and Critical Care Massachusetts General Hospital Boston, Massachusetts [email protected]

Diagnostic accuracy of Doppler-echocardiography in unselected patients with suspected pulmonary embolism

This study investigates the diagnostic value of echocardiography in patients with suspected pulmonary embolism. Doppler-echocardiography was performed in fifty consecutive patients, predominantly presenting in the emergency ward, with clinically suspected pulmonary embolism. Patients were classified as having or not pulmonary embolism by a sequential non-invasive strategy including lung scan, D-dimer measurement and lower limb venous compression ultrasonography, pulmonary angiography being performed in case of an inconclusive non-invasive work-up. The prevalence of pulmonary embolism was 36% (18 of 50 patients). Right ventricular dilatation on 2-D echocardiography associated to a tricuspid regurgitation velocity ≥2.7 m/s, corresponding to a pulmonary systolic pressure ≥39 mmHg, were present in 12 of the 18 patients (67%) with and in two of the 32 patients (6.3%) without pulmonary embolism. They were, however, absent in five of the 18 patients (28%), in whom the definite diagnosis of pulmonary embolism was made. The combination of these both echocardiographic criteria yielded a sensitivity of 67% and a specificity of 94%, positive predictive value was 86% and negative predictive value was 83%. The diagnostic performance of these two combined echocardiographic criteria, when present, permitted to reach in patients with a high clinical pre-test probability of pulmonary embolism the post-test probability values above 90%. On the other hand, the absence of these two Doppler-echocardiographic criteria did not allow to exclude pulmonary embolism, except in presence of a low pre-test probability. The findings of our study show that Doppler-echocardiography in patients with high clinical suspicion of pulmonary embolism may represent a potentially useful screening technique for the diagnosis of the disease permitting prompt initiation of treatment. However, the method does not allow to exclude pulmonary embolism in all patients with intermediate or high clinical suspicion of the disease.

Angioscopic detection of residual pulmonary thrombi in the differential diagnosis of pulmonary embolism

Definite diagnosis of pulmonary embolism (PE) by conventional methods such as angiography is frequently difficult. If residual thromboemboli incorporated into the pulmonary arterial wall or in the distal small segments are visible, differential diagnosis of PE versus primary pulmonary hypertension (PPH) can be made without open-chest pulmonary biopsy. Six patients suspected of having acute PE, 6 suspected of having chronic PE, and 4 with PPH diagnosed by pulmonary biopsy underwent percutaneous pulmonary angioscopy. In patients suspected of having PE, globular and mural thromboemboli were detected by both angioscopy and angiography in 4 and 1 patients, respectively. By angioscopy, emboli incorporated into the arterial wall were detected in 7 and microemboli obstructing the distal small segments were detected in 6. However, these emboli were detected by angiography in none. In patients with PPH, no embolus was detected by angioscopy and angiography. Angioscopically, however, stenoses were observed in the distal small segments in all patients. The results indicate that residual pulmonary thromboemboli in PE and stenoses of distal pulmonary arteries in PPH are detectable by percutaneous angioscopy, and therefore this method is feasible for differential diagnosis of PE.

Pulmonary Embolism

Pulmonary embolism is a common and often fatal postoperative complication. Dyspnea is the most common clinical manifestation in pulmonary embolism, and other signs are frequently inconsistent and often vague. The chest film and electrocardiogram may be helpful in excluding other cardiorespiratory diseases but they are frequently unreliable in establishing an objective diagnosis of pulmonary embolism. Documentation of a decreased arterial saturation provides suggestive evidence of pulmonary embolism. Lung scanning is a safe, sensitive procedure for the initial evaluation of symtoms suggestive of pulmonary embolism, and pulmonary arteriography may be necessary to confirm the diagnosis in certain patients. Anticoagulation is effective in the prevention and treatment of pulmonary embolism and proves successful in the vast majority of patients. Emboli that are not fatal gradually resolve in the pulmonary circulation. Vena caval interruption is occasionally beneficial in selected patients, especially those with septic emboli and cor pulmonale, but should only be performed when the indications are quite clear. Under certain selected circumstances pulmonary embolectomy may be indicated. Patients with massive embolism occluding more than one-half of the pulmonary arterial system and prooducing a markedly elevated pulmonary arterial pressure and severe hypoxemia may die in acute right heart failure. Intractable shock unresponsive to aggressive medical therapy in these patients represents an indication for pulmonary embolectomy. The hazards of these surgical procedures demand that a definite diagnosis of pulmonary embolism be made and a systematic approach to the diagnosis and treatment should be followed in all patients with the disorder.

The spectrum of pulmonary embolism: twenty years later.

A ten-year analysis of the prevalence of pulmonary embolism found at autopsy examination has been repeated 20 years after a prior study. The frequency of all pulmonary embolism (12.3%) and of "major" pulmonary emboli (7.1%) remains essentially unchanged from that detected 20 years previously (13.6% and 8.6%). Less than 10% of patients had the clinical diagnosis of deep leg vein thrombosis, and only 9.3% had a definitive diagnosis of pulmonary embolism made during life. A sixfold variation in quarterly frequency and a twofold variation in annual prevalence were noted. Since these wide fluctuations in frequency are present, any assumptions regarding a changing disease pattern must be made with great caution. There is no evidence that fatal pulmonary embolism has decreased in frequency in recent years. An effort should be made to increase rate of detection of thromboembolic disease by more widespread use of one or more of the recently developed diagnostic procedures, or a larger segment of the hospital population at risk should receive prophylactic therapy with "low-dose" heparin sodium.