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Pulmonary EmbolismDiagnosis without use of chest CT scans: Wells PS, Ginsberg JS, Anderson DR, et al. Use of a clinical model for safe management of patients with suspected pulmonary embolism. Ann Intern Med 1998;129:997-1005. Study used a "minimally invasive" approach to managing patients with suspected PE, emphasizing use of serial dopplers rather than PA grams in patients with a non-diagnostic initial work-up. Approach is comparable to the 1999 ATS guidelines; it does not include CT angiography. A particular strength of the study was the use of set criteria to establish clinical suspicion. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9867786 Wells PS, Anderson DR, Rodger M, et al. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer. Ann Intern Med 2001;135:98-107. Large prospective cohort study using the SimpliRED d-dimer assay (which has sensitivity lower than, and specificity higher than, some other d-dimer tests) found the combination of a low clinical suspicion for PE and a negative d-dimer safely ruled out pulmonary embolism without additional testing. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11453709 Studies suggesting chest CT alone is sufficient to evaluate for PE van Belle A, Buller HR, Huisman MV, et al. Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography. JAMA 2006; 295:172-9. This study classified 3,306 patients as “PE likely” or “PE unlikely” based on a dichotomized version of Wells criteria. “PE unlikely” plus a negative D-dimer sufficiently ruled out PE without further testing (0.5% with PE diagnosis in subsequent 3 months). Patients with “PE likely” or a positive D-dimer underwent CT angiogram. 95% of patients with a negative CT had anticoagulation withheld without further testing and 1.3% were subsequently diagnosed with PE over 3 months. 88% of scans were multidetector row studies. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16403929&query_hl=21&itool=pubmed_docsum Studies suggesting chest CT alone is not sufficient to evaluate for PE Stein PD, Fowler SE, Goodman LR, et al. Multidetector computed tomography for acute pulmonary embolism. N Engl J Med 2006; 354:2317-27. The much-anticipated PIOPED II study of 824 patients found CT angiogram had a sensitivity of 83% and specificity of 96%, excluding the 6% with poor quality images. The sensitivity improved to 90% with addition of CT venography. The positive predictive value was 96% when the result was concordant with a high or low clinical suspicion, but CT was non-diagnostic if there was discordance. For instance, there were 42% false-positives among patients with low clinical suspicion and a positive scan, and 40% false negatives among patients with high clinical probability but negative scan. CTs were primarily performed with 4-slice scanners. The results of a subsequent RCT by Anderson DR et al (JAMA 2007;298:2743-53) also suggest CT angio may yield false-positive results or diagnose clinically insignificant clot. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16738268&query_hl=24&itool=pubmed_docsum Other diagnostic studies Nicod P, Peterson K, Levine M, et al. Pulmonary angiography in severe chronic pulmonary hypertension. Ann Intern Med 1987;107:565-8. This study established the safety of angiography in patients with chronic, severe pulmonary hypertension. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=3631791 Treatment Agnelli G, Prandoni P, Becattini C, et al. Extended oral anticoagulant therapy after a first episode of pulmonary embolism. Ann Intern Med. 2003; 139:19-25. Randomized, non-blinded study of extending anticoagulation beyond 3 months in patients with first episode of idiopathic PE and PE associated with temporary risk factors. Extending anticoagulation in patients with idiopathic PE from 3 to 12 months only delayed onset of what proved to be a high recurrence rate (4-5% per patient-year once off anticoagulation). A more recent study by Campbell IA et al. BMJ 2007;334;674 reported similar findings. These studies highlight the need for new ways of identifying patients at high risk of recurrence so that they can receive indefinite anti-coagulation. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12834314 Konstantinides S, Geibel A, Heusel G, et al. Heparin plus altepase compared with heparin alone in patients with submassive pulmonary embolism. N Engl J Med 2002; 347:1143-50. Randomized, double blind study found lytic therapy in submassive PE did not improve mortality. Patients randomized to lytics were significantly less likely than the placebo group to require escalation of therapy, which primarily entailed administration of lytics. The indication for rescue therapy was worsening respiratory symptoms, short of intubation, two-thirds of the time. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12374874 Prevention with vena caval filters. Thromboendarterectomy for chronic thromboembolic disease Jamieson SW, Kapelanski DP, Sakakibara N, et al. Pulmonary endarterectomy: experience and lessons learned in 1,500 cases. Ann Thorac Surg 2003; 76:1457-64. Summarizes entire UCSD experience with thromboendarterectomy. The most recent 500 cases (through 12/02) are discussed in greater detail. 30-day mortality in this group was 4.4%, which varied according to type of thrombotic lesion and preoperative hemodynamics. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14602267 | |||||||||
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