Suspicion Of Pulmonary Embolism Research Articles

P5019Derivation and validation of a new probability score in pulmonary embolism suspicion allowing safely reduction of imaging testing: PEPS (Pulmonary Embolism Probability Score)

Abstract Background In pulmonary embolism (PE) suspicion, several strategies based on clinical criteria and D-dimer (Dd) measurement have been developed in order to reduce resource utilization. However, they used different clinical probability (CP) assessment methods limiting their combination. Purpose To develop and validate a unique probability score integrating most of previous proposals to allow safely reduction of imaging testing. Methods 4 CP levels were previously defined in order to obtain a false negative rate <1.9%: 1) without Dd test: very low CP (PE prevalence <1.9%), 2) with Dd <1000 μg/L: low CP (<15%), 3) with Dd <500 or age x10μg/L: moderate CP (<60%) and 4) precluding PE exclusion on Dd: high CP. We used individual data from 4 prospective cohorts of suspected PE patients in Europe and America (n=11 066) for derivation and internal validation. The variables significantly associated with PE in univariate analysis were included in a multivariate logistic regression model. Points were assigned according to the regression coefficients. The score was validated in two external independent cohorts (n=1554, n=1669). Results PEPS comprised 13 variables: age <50 years (−2), age 50–64 years (−1), heart rate <80 beats/min (−1), chronic lung disease (−1), chest pain and recent dyspnea (+1), syncope (+1), male sex (+1), previous venous thromboembolism (+2), medical or orthopaedic immobilization (+2), estrogenic treatment (+2), oxygen saturation <95% (+3), unilateral lower limb pain (+3) and PE is the most likely diagnosis (+ 5). The rates of false negative and avoidable imaging tests if the PEPS strategy would have been applied were 0.6% [95% CI: 0.3–1.1] and 22.7% [20.2–25.3] in the first external validation cohort, and 0.85 [0.5–1.45] and 26.6% [23.5–29.9] in the second one. Applied retrospectively, PEPS strategy compared favourably with other strategies and combinations. Derivation Int. validation Ext. validation 1 Ext. validation 2 nPE/N % [95% CI] nPE/N % [95% CI] nPE/N % [95% CI] nPE/N % [95% CI] TOTAL 615/5588: 11.0% [10.2–11.9] 432/3726: 11.6% [10.6–12.7] 327/1546: 21.2% [19.2–23.2] 196/1669: 11.7% [10.3–13.4] Very low CP PEPS<0 16/1445: 1.1% [0.7–1.8] 16/946: 1.7% [1.0–2.7] 3/118: 2.5% [0.7–6.8] 5/347: 1.4% [0.6–3.3] Low CP 0≤PEPS<5 127/2620: 4.9% [4.1–5.7] 106/1805: 5.9% [4.9–7.1] 49/611: 8.0% [6.1–10.4] 61/647: 7.2% [5.7–9.1] Moderate CP 5≤PEPS<12 347/1334: 26.0% [23.7–28.4] 243/867: 28.0% [25.1–31.1] 206/715: 28.8% [25.6–32.2] 107/430: 24.9% [21.0–29.2] High CP 12≤PEPS 125/179:69.8% [62.8–76.1] 67/108: 62.0% [52.6–70.6] 69/102: 67.7% [58.1–76.2] 23/45: 51.1% [37.0–65.0] AUC 0.84 [0.83–0.86] 0.82 [0.80–0.84] 0.79 [0.76–0.82] 0.77 [0.74–0.80] CP: Clinical probability; PEPS: Pulmonary Embolism Probability Score. Conclusions A strategy based on the proposed score may lead to a safely substantial reduction of imaging testing. It should now be tested in an outcome interventional study.

1771P - Performance of the ‘4S rule’ to predict short-term outcomes in cancer outpatients with unsuspected pulmonary embolism

BackgroundThe diagnosis of incidental or unsuspected pulmonary embolism (PE) in cancer outpatients undergoing scheduled CT-scans is a challenge in daily oncological practice. The aim of this study was to assess the performance of the ‘4S rule’ (Setting, Suspicion, Signs and Symptoms) as a PE risk-assessment model in this setting. MethodsWe assessed consecutive patients with cancer-associated PE from an ongoing multicenter observational registry (2005-2018). Patients were classified as presenting ‘Truly asymptomatic unsuspected PE’ (TAUPE) according to the ‘4S rule’ (EurRespir J 2017;49(1):1600282 and EurRespir J 2017;49(1):1602225) that includes the following variables: (1) outpatient Setting at PE diagnosis; (2) no Suspicion of PE; (3) vital Signs within normal limits including blood pressure >100mmHg, heart rate <100 per minute and oxygen saturation >95%; and (4) absence of PE Symptoms. Short-term outcome measures included: all-cause and PE-related mortality within 30 days after the index PE. ResultsWe evaluated a total of 617 patients (61.6% male; median age 65+11.4 years) including 207 (33%) with TAUPE, 284 (47%) with ‘acute suspected PE’ and 126 (20%) with ‘unsuspected PE with symptoms’. Most patients (79%) had metastatic cancer and nearly half (47%) were on chemotherapy. The PE was incidentally found in 54% of the cohort. The most frequent tumors were: 32% lung, 14% colorectal, 13% urological, and 12% upper gastrointestinal. All-cause 30-day mortality occurred in 95 patients (15% of the cohort) and 12 cases presented PE-related mortality (2% of the cohort). Patients with TAUPE had lower all-cause 30-day mortality compared to non-TAUPE cases (3% vs. 22%; p<0.0001). PE-related 30-day mortality occurred in 0 patients with TAUPE and in 12 (3%) non-TAUPE patients (0% vs. 3%; p=0.013). ConclusionsShort-term mortality in patients with cancer-associated PE is high. Cancer outpatients with TAUPE according to the 4S rule criteria (33% in the cohort) were identified as a low-risk group of all-cause and PE-related short-term mortality. These findings may help to develop PE risk-assessment models in this setting. Legal entity responsible for the studyHospital Clinic de Barcelona. FundingHas not received any funding. DisclosureAll authors have declared no conflicts of interest.

New d-dimer threshold for Japanese patients with suspected pulmonary embolism: a retrospective cohort study

BackgroundIn the diagnosis of pulmonary embolism (PE), the d-dimer threshold is based on studies conducted in Western countries, where the incidence rate is 5 times higher than that in Asian countries, including Japan. If we could elevate the d-dimer threshold based on the low pre-test probability in the Japanese population, we could omit the computed tomography pulmonary angiography (CTPA) which might lead to radiation exposure and contrast-induced nephropathy. Therefore, we aimed to determine a new d-dimer threshold specific to Japanese individuals.MethodsWe conducted a retrospective cohort study at an emergency department in Japan, using medical charts collected from January 2013 to July 2017. We included patients whose d-dimer were measured for suspicion of PE with low or intermediate probability of PE and CTPA were performed. The primary outcome was failure rate of the new d-dimer threshold, defined as the rate of PE detected by CTPA among patients with d-dimer under the new threshold ranging from 1000 to 1500 μg/L by 100. The new d-dimer threshold was appropriate if the upper limit of 95% confidence interval of the failure rate of PE was approximately 3%.ResultsIn 395 patients included, the number of patients with PE was 24 (the prevalence was 6.1%). If the d-dimer threshold was 1100 μg/L, the failure rate was 0% (0/119), the upper limit of the 95% confidence interval of the failure rate was 3.1%, and 30% (119/395) of the CTPA might be omitted.ConclusionThe new d-dimer threshold could safely exclude PE. This result can be generalized to other Asian populations with a lower incidence of PE. Further prospective studies will be needed.

Diagnostic validity of thoracic ultrasound in the assessment of pulmonary embolism

BackgroundTo determine the sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of thoracic ultrasound (TUS) in patients with moderate to high clinical suspicion of pulmonary embolism (PE). Twenty-five patients with moderate or high clinical suspicion of PE were enrolled in a prospective study. The patients’ ages were 20 to 50 years (mean age = 36 years). They were evaluated by TUS and standard contrast-enhanced CT pulmonary angiography (CTPA).ResultsIn comparison to and in correlation with CTPA, TUS was found true positive in 12 patients (48%), false positive in one patient (4%), true negative in eight patients (32%), and false negative in four patients (8%), with an overall sensitivity (75%), specificity (89%), positive predictive value (92%), negative predictive value (67%), and accuracy (80%).ConclusionTUS with its high specificity and diagnostic accuracy is a noninvasive, widely available, cost-effective method which can be rapidly performed. A negative TUS study cannot rule out PE with certainty, but positive TUS findings with moderate/high suspicion for PE may prove a valuable bedside tool in the diagnosis of PE especially for critically ill and immobile patients, facilitating their immediate treatment.

Pulmonary Vein Sign on Unenhanced-MRI as a Sign of Severe Pulmonary Embolism

Background: Increased right ventricle-to-left ventricle (RV/LV) ratio on computed tomography pulmonary angiography (CTPA) has been reported as a poor prognostic indicator in patients with acute pulmonary embolism (PE). It has also been reported that pulmonary vein sign (PVS) on CTPA is a rare finding of PE. Objectives: To evaluate PVS on CTPA and unenhanced magnetic resonance imaging (MRI) in patients with PE suspicion. We also aimed to investigate the relationship between the severity of PE and presence of PVS, RV/LV ratio and combination of these two on unenhanced MRI. Patients and Methods: One-hundred-twelve patients with PE suspicion who underwent CTPA and unenhanced-MRI [steady state free precession (SSFP)] within the first 48-hours constituted the study group. All CTPA images were evaluated for the presence, location and severity of PE by observer-1. Two observers (observer-2 and 3), independently evaluated unenhanced-MR images for the presence of PVS without knowing the results of CTPA. Then, these 2 observers reviewed the CTPA and MRI images together with observer-4 to reach the final consensus for the presence of PVS and measurement of RV/LV ratio. Cohen’s Kappa analysis was used to assess the agreement between observers. Relationship between the mean PE index and imaging findings (PVS, RV/LV) were calculated. Results: Presence of PVS on CT or MRI is significantly correlated with PE index and patients with PVS had more severe PE than those without. Presence of both PVS and RV/LV ratio > 1 on MRI indicates more severe pulmonary embolism than absence of PVS or RV/LV ratio > 1. There was a very good agreement for the detection of PVS between two observers on unenhanced MRI. Conclusion: PVS on CTPA or unenhanced MRI can be used as a sign of severe PE and it may also be an indicator of right heart dysfunction.

P046: Proposed methodology to determine the optimal diagnostic strategy for pregnant women with suspicion of pulmonary embolism

P046: Proposed methodology to determine the optimal diagnostic strategy for pregnant women with suspicion of pulmonary embolism

Diagnostic de l’embolie pulmonaire

The diagnosis of pulmonary embolism (PE) is nowadays based on the sequential use of several diagnostic tests rather than on a single test. These diagnostic strategies are safe and have been prospectively validated. The first step after identifying patients with suspicion of PE is to establish the pre-test clinical probability. Several scores are available in order to make a standardised and reproducible assessment of the clinical probability, and therefore represent precious diagnostic tools. Indeed, clinical probability guides further investigations. Indeed, in patients with a low or an intermediate clinical probability or an “unlikely” probability, PE can be safely ruled out by negative D-dimers in approximately one third of outpatients without additional imaging. In case of positive D-dimers and a high clinical probability or a “likely” clinical probability, CT pulmonary angiography is now the recommended imaging technique. However, lower limb venous compression ultrasound and ventilation/perfusion scans remain useful in patients with contra-indications to CT, mainly those with renal insufficiency. Finally, some novel diagnostic tests seem promising. For example, V/Q SPECT has arisen as a highly accurate test and a potential alternative to CTPA. However, prospective management outcome studies are still lacking and are warranted before its implementation in routine clinical practice.

Evaluation of Rescue Thrombolysis in Cardiac Arrest Secondary to Suspected or Confirmed Pulmonary Embolism.

Pulmonary embolism (PE) is the associated cause of unexplained cardiac arrest in 5% to 13% of patients. Although thrombolytic agents have been studied, patient outcomes during cardiac arrest are lacking. The purpose of this study was to describe outcomes of patients who received thrombolytic therapy during cardiac arrest for suspected or confirmed PE. This retrospective review included adults who received alteplase or tenecteplase during cardiac arrest for suspected or confirmed PE. The primary end point was incidence of survival to hospital discharge, whereas secondary end points included a description of dosing strategies of thrombolytic therapy, the incidence of return of spontaneous circulation (ROSC), the occurrence of minor or major bleeding, and intensive care unit and hospital lengths of stay. Of the 22 patients included in the study, 3 patients (13.6%) survived to hospital discharge, and ROSC was obtained in 11 patients (50%). Three patients had confirmed PE prior to cardiac arrest, with the remaining 19 patients having a documented suspicion for PE. The most frequent dosing strategy was alteplase 100 mg given via intravenous push (13 of 22 patients; 59%). One minor and no major bleeding events occurred. Conclusion and Relevance: Medical advances in PE management continue to evolve; yet the role of thrombolytic therapy in PE-related cardiac arrest remains unclear, with low overall rates of survival. These findings add to the relatively small body of evidence and highlight that optimal dosing remains unknown in this setting.

Role of hemogram parameters in diagnosis and assessing severity of pulmonary embolism

Introduction To investigate the changes in platelets indices in patients with pulmonary embolism (PE) and to examine the correlation of these parameters with the extent of vascular occlusion. Patients and methods The present study was conducted on 70 patients who were admitted because of clinical suspicion of PE. For all patients, complete history taking and examination, routine laboratory investigations, chest radiography, ECG, and transthoracic echocardiography were done. For patients with low and intermediate clinical probability, assessment of d-dimer level was done. For patients with high clinical probability and those with positive d-dimer finding, pulmonary computed tomography angiography was performed with measurement of pulmonary artery obstructive index (PAOI) and right ventricle to left ventricle (RV/LV) ratio. Results Fifty patients were confirmed to have PE and the remaining 20 patients were negative for PE. The group of patients without PE served as a control group. The differences in platelet count, mean platelet volume (MPV), platelet distribution width (PDW), red cell distribution width, and other parameters were compared between both the groups. MPV and PDW were significantly higher in patients with acute PE than in other patients (P=0.0002 and 0.0001). A significant correlation was found between MPV and both PAOI (P=0.049) and RV/LV ratio (P=0.0004). Moreover, significant correlation between PDW and PAOI (P=0.001) and between PDW and RV/LV (P=0.044) was found. The best cutoff value for MPV for the prediction of RV dysfunction was more than 9.4 fl (sensitivity 46.7%; specificity 94.7%). The best cutoff value for PDW for the prediction of RV dysfunction was more than 15.85 fl (sensitivity 75%; specificity 65.9%; P=0.006).

Primary diagnosis of pulmonary embolism with unenhanced MRI for patients not eligible for CTPA: Clinical outcome

PurposeTo follow up the clinical outcome of patients with suspected pulmonary embolism (PE), in those only imaged using unenhanced, free-breathing magnetic resonance imaging (MRI). Methods and materialsFifty-seven patients aged 29–99 years (mean 70, SD 18) that could not undergo Computed Tomography Pulmonary Angiography (CTPA) were offered alternative imaging diagnostics in parallel with ongoing methodological studies validating MRI vs CTPA. Contraindications included renal failure (n = 44), severe iodine contrast allergy (n = 10), pregnancy (n = 2) and radioactive iodine therapy (n = 1). The unenhanced MRI protocol was based on free-breathing, steady-state free precession with no cardiac or respiratory gating. Retrospective review of the electronic medical record (EMR) was made of 0–12 months post-imaging and was collected during 2012–2018. ResultsAll 57 MRIs were of diagnostic quality and 12 pulmonary embolisms were diagnosed. Of the 57 patients, 44 were already on, or had started anticoagulation therapy due to clinical suspicion of PE. Four of the patients were put on anticoagulation after the positive MRI and 13 were taken off anticoagulation after a negative MRI report. Other diagnoses reported (considering dyspnea) were pleural effusion (n = 24), consolidation (n = 12) and pericardial effusion (n = 2). One patient had a deep vein thrombosis (DVT) within three months of our negative MRI result and then had a stroke within one year. Another patient suffered a stroke within three months of being diagnosed (by MRI) with PE and given anticoagulation as treatment. ConclusionsOur method supported or altered clinical decision-making and treatment in this cohort. A diagnostic tool for PE without intravenous contrast agent or radiation is of great benefit for certain patients.

Comparison of Image Quality of Low Voltage 64-slice Multidetector CT Angiography with the Standard Condition in Patients Suspected of Pulmonary Embolism

Introduction: Reduction of peak kilovoltage (kV) setting has been a useful approach to d creating radiation dose; however, it may have varied effects on noise and the accuracy of diagnosis. Thus, we compared image quality between low (80 kV) and standard kilovoltage (100 kV) protocols. Material and Methods: This triple blind non-randomized parallel quasi-experimental study was conducted on 140 cases of questionable pulmonary embolism. Results: Image quality was twice as high as the standard protocol in the 80-kV group (odds ratio=2.08). Main, segmental, and subsegmental arteries showed significantly higher vascular enhancement (P<0.001) in the 80-kV group. Similarly, the mean number of measurable segmental arteries was significantly greater in the 80-kV group relative to the standard group. On the other hand, the mean of image noise was significantly higher in the 80-kV group in comparison with the 100-kV group (mean: 68.4 vs. 43.1; P<0.001). Finally, the mean of radiation dose received in the 80-kV group was significantly lower than that in the 100-kV group (mean: 0.94 vs. 2.43 mSv; P<0.001). Conclusion: Lower radiation dose received and higher image quality, but worse image noise, in the 80-kV group compared to the 100-kV group present acceptable evidence in support of reduction of voltage in cases with the suspicion of pulmonary embolism. In these patients, therefore, it is recommended as a good strategy to be adopted in computed tomography angiography.

CATHETER DIRECTED THROMBOLYSIS FOR MASSIVE PULMONARY EMBOLISM IN A PREGNANT PATIENT

SESSION TITLE: Critical Care 2 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Pulmonary embolism (PE) is a leading cause of maternal mortality in the United States [1]. CASE PRESENTATION: We report a 27-year-old female at 13 weeks gestation who presented with massive PE and circulatory shock and was successfully treated with catheter directed thrombolysis. History of syncope prior to arrival combined with EKG changes and findings on bedside ultrasound led to a high clinical suspicion for PE with diagnosis confirmed by computed tomography. The patient was admitted to the intensive care unit on systemic anticoagulation with unfractionated heparin. Subsequent circulatory shock led to the decision for catheter directed thrombolytic therapy. The advantage of our treatment choice was rapid clot lysis, return of normal hemodynamics, and avoidance of the risk of complications associated with higher doses of thrombolytic agents [2]. The patient remained hospitalized for 5 days without complication and was discharged on low-molecular weight heparin injections. DISCUSSION: The morbidity and mortality associated with PE during pregnancy demands prompt diagnosis and treatment. In general, thrombolytic agents are relatively contraindicated during pregnancy because of the presumed risk of maternal bleeding and fetal loss. The teratogenicity for these agents in humans is also uncertain [3]. CONCLUSIONS: Ultimately, all life-saving measures must be considered in the face of hemodynamic collapse. Our case demonstrates a positive outcome from catheter directed thrombolytic therapy and contributes to the growing literature in outcomes of treatment in massive PE in pregnancy. Reference #1: 1 Creanga, Andreea A., et al. “Pregnancy-Related Mortality in the United States, 2006-2010.” Obstetrics & Gynecology, vol. 125, no. 1, Jan. 2015, pp. 5–12., https://doi.org/10.1097/aog.0000000000000564. Reference #2: 2 Brandt, Kimberly, et al. “Low-Dose Systemic Alteplase (TPA) for the Treatment of Pulmonary Embolism.” Annals of Pharmacotherapy, vol. 49, no. 7, Sept. 2015, pp. 818–824., https://doi.org/10.1177/1060028015579988. Reference #3: 3 Ahearn GS, Hadjiliadis D, Govert JA, Tapson VF. Massive Pulmonary Embolism During Pregnancy Successfully Treated With Recombinant Tissue Plasminogen ActivatorA Case Report and Review of Treatment Options. Arch Intern Med. 2002;162(11):1221–1227. https://doi.org/10.1001/archinte.162.11.1221 DISCLOSURES: No relevant relationships by daniel goldbach, source=Web Response

A CASE OF MASSIVE PULMONARY EMBOLISM CAUSING VENTRICULAR FIBRILLATION AND CARDIAC ARREST

SESSION TITLE: Critical Care 1 SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Massive Pulmonary Embolism (PE) is a known noncardiac cause of circulatory arrest, it is associated with very poor outcomes and high mortality. We herein report a unique case of cardiac arrest due to massive PE that presented with a dominant rhythm of Ventricular Fibrillation (VF). CASE PRESENTATION: A 42-year-old male with past medical history of morbid obesity and chronic back pain; presented to our hospital with acute on chronic low back pain and inability to ambulate. On admission, vital signs were normal. Physical examination showed signs of left lower extremity radiculopathy. Often times and because of the pain severity, patient used to refuse to participate in physical therapy and assisted ambulation. Given that, patient was on appropriate pharmacological deep venous thrombosis prophylaxis. During hospitalization, the patient was found unresponsive and pulseless, code blue was activated and cardiopulmonary resuscitation was started. Upon connecting it, the cardiac monitor showed VF rhythm (Image 1) for which a shock was delivered. After few minutes, return of spontaneous circulation achieved. A 12-lead electrocardiogram demonstrated sinus tachycardia and new right bundle branch block (Image 2) and that triggered the suspicion of PE. A stat bedside echocardiogram revealed dilatation of the right ventricle. Computed Tomography of chest with intravenous contrast (PE protocol) confirmed the diagnosis of PE in the left and right main pulmonary arteries(Image 3). As a result, systemic thrombolytic therapy was initiated. Few hours later, the patient went into three successive episodes of cardiac arrest in which VF was the recurrent rhythm and multiple shocks were delivered. DISCUSSION: PE is the third most common cause of hospital-related death[1]. The vast majority of VF cases are strongly linked to cardiac events; mainly coronary artery disease due to ischemia[2]. On the other hand, PE with circulatory arrest is highly associated with pulseless electric activity (PEA) followed by asystole[3]. For VF to be the dominant rhythm in the setting of cardiac arrest due to massive PE and without any evidence of myocardial ischemia is unreported. This case highlights the importance of considering PE in the differential diagnosis of cardiac arrest causes when the presenting and the dominant rhythm is VF particularly in the absence of myocardial ischemia. CONCLUSIONS: To our knowledge, this is the first case in the literature to provide a direct link between PE and VF in the context of circulatory arrest. It is crucial to recognize the initial rhythm that is associated with the cardiac arrest as it may guide toward the etiology of the arrest. While, PEA and asystole are by far the most common rhythms in massive PE with cardiac arrest, our case should encourage physicians to also consider PE as a possible cause of cardiac arrest when VF is the main rhythm and no signs of cardiac ischemia exist. Reference #1: Lindblad B, Eriksson A, Bergqvist D. Autopsy-verified pulmonary embolism in a surgical department: analysis of the period from 1951 to 1988. Br J Surg. 1991;78:849–852. [PubMed] Reference #2: Warnes CA, Roberts WC. Sudden coronary death: relation of amount and distribution of coronary narrowing at necropsy to previous symptoms of myocardial ischemia, left ventricular scarring and heart weight. Am J Cardiol. 1984 Jul 1. 54(1):65-73. Reference #3: Kürkciyan I, Meron G, Sterz F, Janata K, Domanovits H, Holzer M, Berzlanovich A, Bankl HC, Laggner AN. Pulmonary Embolism as Cause of Cardiac ArrestPresentation and Outcome. Arch Intern Med.2000;160(10):1529–1535. https://doi.org/10.1001/archinte.160.10.1529 DISCLOSURES: No relevant relationships by Michel Chalhoub, source=Web Response No relevant relationships by halim el hage, source=Web Response No relevant relationships by Cheikh Talal El Imad, source=Web Response No relevant relationships by Ahmad Itani, source=Web Response No relevant relationships by boutros karam, source=Web Response No relevant relationships by Ahmed Mahgoub, source=Web Response No relevant relationships by chadi salmane, source=Web Response No relevant relationships by Jay Solanki, source=Web Response

Dyspnea in the emergency department at night

Acute pulmonary embolism (PE) interferes with both blood circulation and gas exchange. Right ventricular failure due to pressure overload is considered the leading cause of death by PE. The diagnosis of PE can be difficult, as the symptoms are often non-specific (dyspnea, chest pain, pre-syncope or syncope, hemoptysis). In particular, chest pain may be typical and derive from ischemia of the right ventricle: in these cases a differential diagnosis with acute coronary syndrome or with aortic dissection is necessary. If EP is suspected, it is therefore necessary to proceed promptly to the recommended diagnostic investigations. The case of a 62-year-old smoker suffering from arterial hypertension, dyslipidemia, non-insulin-dependent diabetes and chronic ischemic heart disease is reported here, admitted to emergency room for increasing dyspnea from mild stress in the absence of trauma, prolonged bed rest or fever. In suspicion of PE, CT angiography with contrast agent was performed for the study of the arterial tree, which confirmed the diagnosis of venous thromboembolism. The patient is treated with supporting tights, unfractionated heparin, and dabigatran is subsequently started (Cardiology).

OA082] Towards normalization of contrast enhancement of pulmonary parenchyma on subtraction CT imaging

Purpose To determine the impact of patient and acquisition parameters on the quantification of the enhancement of pulmonary parenchyma in subtraction computed tomography pulmonary angiography (CTPA) imaging in patients without pulmonary pathology. Methods 2515 patients underwent clinical CTPA with subtraction imaging on a 320-multidetector row CT scanner (Aquilion ONE VISION or GENESIS, Canon Medical Systems Corporation, Japan) between January 2013 and August 2017 for suspicion of pulmonary embolism. In subtraction CT, an unenhanced chest CT is subtracted from an enhanced CT after motion correction, resulting in an iodine map representing pulmonary perfusion. After examination of patient records and images, 74 patients (2.9 %) without any apparent pulmonary or systemic pathology were selected. The mean enhancement in circular regions of interest (ROI) in all lung lobes of the iodine maps, placed to avoid vessels depicted in the CTPA images, were calculated. Patient age, sex, BMI, and smoking habits, as well as CT scan time, diaphragm position and lung volume changes between the unenhanced and enhanced CT, type and volume of contrast, and enhancement in the aortic arch, pulmonary trunk and left atrium were collected. Linear regression analysis was used to evaluate the correlation between the parameters and the measured enhancement. Results The mean enhancement of the ROIs throughout the whole lung was 32.2 ± 21.6 HU. The enhancement in the lower lobes (39.4 ± 24.3 HU) was significantly higher than in the upper lobes (31.7 ± 22.3 HU, p r 2 = 0.54 p 0.001 ) , and with lung volume changes ( r 2 = 0.73 p 0.001 ) between the scans. No correlation was found between the mean enhancement and all other variables studied. Conclusions The enhancement of the pulmonary parenchyma on subtraction CT imaging in patients without pulmonary pathology varies widely. However, normal enhancement values correlate strongly with changes in diaphragm position and in pulmonary volume between scans. This implies that normalization of lung enhancement based on lung volume changes could improve clinical interpretation and would be the first step towards quantification of enhancement in subtraction CT imaging.

Magnetic resonance angiography for the primary diagnosis of pulmonary embolism: A review from the international workshop for pulmonary functional imaging.

Pulmonary contrast enhanced magnetic resonance angiography (CE-MRA) is useful for the primary diagnosis of pulmonary embolism (PE). Many sites have chosen not to use CE-MRA as a first line of diagnostic tool for PE because of the speed and higher efficacy of computerized tomographic angiography (CTA). In this review, we discuss the strengths and weaknesses of CE-MRA and the appropriate imaging scenarios for the primary diagnosis of PE derived from our unique multi-institutional experience in this area. The optimal patient for this test has a low to intermediate suspicion for PE based on clinical decision rules. Patients in extremis are not candidates for this test. Younger women (< 35 years of age) and patients with iodinated contrast allergies are best served by using this modality We discuss the history of the use of this test, recent technical innovations, artifacts, direct and indirect findings for PE, ancillary findings, and the effectiveness (patient outcomes) of CE-MRA for the exclusion of PE. Current outcomes data shows that CE-MRA and NM V/Q scans are effective alternative tests to CTA for the primary diagnosis of PE.

An Article on Investigative Pitfalls in Pulmonary Hypertension

If the clinical presentation of patients with new pulmonary hypertension (pHTN) creates a strong index of suspicion for an underlying cause, all investigative avenues should be exhausted prior to excluding this diagnosis, to ensure the receipt of appropriate treatment. We present a case that exemplifies this issue. A 23-year-old female from a remote community presented with chest pain, fever, and a sore throat on a background of recently diagnosed systemic lupus erythematous. She was transferred to a tertiary hospital for further management. Physical examination revealed sinus tachycardia and a fever (38.0 °C); however, systems examination was unremarkable. Inflammatory markers were elevated with reduced complement levels and high-sensitivity troponin I of 22 ng/L. Electrocardiogram showed widespread T-wave inversion. Echocardiogram demonstrated right heart strain with new pHTN (vs 1 month prior) and McConnell's sign. Computed toography pulmonary angiogram (CTPA) excluded large-calibre pulmonary embolism (PE). Colchicine was commenced for a preliminary diagnosis of pericarditis secondary to a SLE flair. Right heart catheterisation confirmed pHTN. Despite a negative CTPA, new pHTN, and echocardiographic signs created a strong suspicion for PE. V/Q scan identified bilateral mismatches consistent with this diagnosis and therapeutic anticoagulation was commenced. Further investigation revealed antibodies suggestive of anti–phospholipid syndrome. This case demonstrates that if there is a strong index of suspicion for PE and the resultS of a CTPA are not confirmatory, alternative diagnostic modalities should be sought. There is a need for clear delineation of aetiology of pulmonary hypertension to ensure appropriate treatment.

Clinical characteristics of children evaluated for suspected pulmonary embolism with D-dimer testing

BackgroundWe sought to determine clinical variables in children tested for suspected pulmonary embolism (PE) that predict PE+ outcome for the development of paediatric PE prediction rule.MethodsData were collected by query...

Monocyte to large platelet ratio as a diagnostic tool for pulmonary embolism in patients with acute exacerbation of chronic obstructive pulmonary disease.

INTRODUCTION A higher prevalence of pulmonary embolism (PE) has been noted among patients with chronic obstructive pulmonary disease (COPD), particularly in those with acute exacerbations of COPD (AECOPD). Due to a similar clinical presentation and the lack of highly specific laboratory tests, there is a common overuse of computed tomography pulmonary angiography (CTPA). The introduction of an additional, simple, and inexpensive diagnostic tool to help in the diagnosis of PE in patients with AECOPD would be of special interest for everyday clinical practice. OBJECTIVES The aim of the study was to assess the usefulness of the monocyte to large platelet ratio (MLPR) as a diagnostic tool for PE in patients with AECOPD. PATIENTS AND METHODS We performed a retrospective evaluation of patients with AECOPD and suspicion of PE who underwent CTPA. The MLPR was investigated as a marker of thrombosis. Receiver operating characteristics (ROC) curve analyses were preformed to measure the accuracy of the MLPR in comparison with CTPA results and to identify the cutoff value for the MLPR. RESULTS A total of 101 patients (56 men and 45 women; median age, 72 years; range, 37-94 years) were included in the study. The MLPR showed an excellent accuracy in comparison with CTPA results: the area under the ROC curve was 0.945 (95% confidence interval [CI], 0.904-0.986). The MLPR was characterized by a good accuracy of qualitative test parameters, with high sensitivity (100%; 95% CI, 79.6-100) and specificity (85.7%; 95% CI, 75.9-92.6). CONCLUSIONS The MLPR measurement appears to be a reliable, simple, inexpensive, and widely available test that may help in the differential diagnosis of PE in patients with AECOPD.

"Pulmonary Vein Sign" for Pulmonary Embolism Diagnosis in Computed Tomography Angiography.

Considering that pulmonary arterial obstruction decreases venous flow, we hypothesized that filling defects in pulmonary veins can be identified in areas adjacent to pulmonary embolism (PE). This sign was named the "pulmonary vein sign" (PVS), and we evaluated its prevalence and performance for PE diagnosis in computed tomography pulmonary angiography (CTPA). This retrospective study enrolled consecutive patients with clinical suspicion of PE who underwent CTPA scan. The PVS was defined by the following criteria: (a) presence of a homogeneous filling defect of at least 2cm in a pulmonary vein; (b) attenuation of the left atrium>160 Hounsfield units. Using the cases that presented PE on CTPA as reference, sensitivity, specificity, and positive and negative predictive values were calculated for PVS. In total, 119 patients (73 female; mean age, 62years) were included in this study. PE was diagnosed in 44 (35.8%) patients. The PVS was present in 16 out of 44 patients with PE. Sensitivity was 36.36% (95% confidence interval (CI) 22.83-52.26%); specificity, 98.67% (95% CI 91.79-99.93%); positive predictive value, 94.12% (95% CI 69.24-99.69%); negative predictive value, 72.55% (95% CI 62.67-80.70%). The Kappa index for the PVS was good (0.801; 95% CI 0.645-0.957). PVS was correlated with lobar and segmental pulmonary embolism (p<0.01). Despite a low sensitivity, presence of the pulmonary vein sign was highly specific for PE, with a good agreement between readers. This sign could contribute for PE diagnosis on CTPA studies.