Challenges in Managing Isolated Subsegmental Pulmonary Embolism

Vinson, David R.; Isaacs, D.; Taye, Etsehiwot; Balasubramanian, M.J.

doi:10.7812/tpp/21.077

Cited by 5 publications

(9 citation statements)

References 43 publications

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“…Two of these patients met our modified CHEST criteria for surveillance, and none met our enhanced criteria. Three patients who had not received anticoagulation were started on anticoagulants upon follow-up with their respective primary care physicians, each of whom had consulted specialists for treatment advice . Two patients remained without anticoagulation without receiving surveillance imaging within 2 weeks; one of these patients was scheduled for a follow-up CTPA, but the imaging study was not completed.…”

Section: Resultsmentioning

confidence: 99%

“…19,20 Although the eligibility criteria vary, the European Society of Cardiology and a multispecialty panel of VTE experts also recommend structured surveillance for select patients with low-risk subsegmental PE. 14,15,24 The prevalence of surveillance strategies in community practice, even in settings with excellent follow-up, is unclear. The proportion of outpatients with acute subsegmental PE who would be eligible for structured surveillance is also unclear.…”

Section: Introductionmentioning

confidence: 99%

“…Approximately 3% to 12% of PEs diagnosed using CTPA are subsegmental . The pharmacological treatment of patients with low-risk subsegmental PE is contested . It is unclear whether the risk of progressive or recurrent venous thromboembolism (VTE) is sufficiently elevated to justify anticoagulation for all patients with subsegmental PE.…”

Section: Introductionmentioning

confidence: 99%

“…Kearon et al acknowledged that the “evidence supporting our recommendations is low quality because of indirectness and because there is limited ability to predict which patients will have VTE complications without anticoagulation.” (p339) This cautious recommendation was reiterated in the subsequent 2021 CHEST guideline and expert panel report . Although the eligibility criteria vary, the European Society of Cardiology and a multispecialty panel of VTE experts also recommend structured surveillance for select patients with low-risk subsegmental PE …”

Section: Introductionmentioning

confidence: 99%

“… 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 The pharmacological treatment of patients with low-risk subsegmental PE is contested. 4 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 It is unclear whether the risk of progressive or recurrent venous thromboembolism (VTE) is sufficiently elevated to justify anticoagulation for all patients with subsegmental PE. The alternative to anticoagulation is a structured surveillance program, consisting of close follow-up, careful instructions for when to seek urgent medical attention, and serial lower-extremity compression ultrasonography to evaluate for deep vein thrombosis (DVT) on day 0 and again at 1 week.…”

Section: Introductionmentioning

confidence: 99%

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Prevalence of and Eligibility for Surveillance Without Anticoagulation Among Adults With Lower-Risk Acute Subsegmental Pulmonary Embolism

Rouleau,

Balasubramanian,

Huang

et al. 2023

JAMA Netw Open

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ImportanceApproximately 8% of acute pulmonary emboli are confined to the subsegmental arteries. The 2016 and 2021 American College of Chest Physicians (CHEST) guidelines and expert panel reports suggest the use of structured surveillance without anticoagulation for select ambulatory patients with subsegmental pulmonary embolism who do not have active cancer, deep vein thrombosis, impaired cardiopulmonary reserve, marked symptoms, or increased risk of recurrent venous thromboembolism; however, guideline uptake in community practice is unknown, as is the proportion of outpatients eligible for surveillance.ObjectiveTo describe the prevalence of surveillance among outpatients with acute subsegmental pulmonary embolism and to estimate the proportion of patients eligible for structured surveillance using modified CHEST criteria.Design, Setting, and ParticipantsThis retrospective cohort study was conducted across 21 US community hospitals in the Kaiser Permanente Northern California integrated health system from January 1, 2017, to December 31, 2021. Adult outpatients with acute subsegmental pulmonary embolism were included. Patients with the following higher-risk characteristics were excluded: codiagnoses requiring hospitalization, non–low-risk vital signs (ie, systolic blood pressure &lt;90 mm Hg, pulse ≥110 bpm, or peripheral cutaneous pulse oximetry ≤92%), prediagnosis anticoagulant use, or hospice care. Data analysis was performed from November 2022 to February 2023.Main Outcomes and MeasuresThe main outcomes were the (1) prevalence of surveillance and (2) eligibility for surveillance using 2 sets of criteria: the CHEST criteria modified by excluding patients with higher-risk characteristics or right ventricular dysfunction and a stricter set of criteria requiring age younger than 65 years and no more than 1 embolus. The prevalence of structured surveillance was calculated and the proportion of patients eligible for surveillance was estimated.ResultsOf the 666 outpatients with acute subsegmental pulmonary embolism included in this study, 229 with lower-risk characteristics were examined. Their median age was 58 (IQR, 42-68) years; more than half were men (120 [52.4%]) and self-identified as non-Hispanic White (128 [55.9%]). Six patients (2.6%) were initially not treated with anticoagulants. Among the lower-risk cohort, only 1 patient (0.4% [95% CI, 0.01%-2.4%]) underwent structured surveillance, without 90-day sequelae. Thirty-five patients (15.3% of the lower-risk group and 5.3% of the full cohort) were surveillance eligible using modified CHEST criteria. Fifteen patients (6.6% of the lower-risk group and 2.3% of the full cohort) were surveillance eligible using stricter criteria.Conclusions and RelevanceIn this cohort study of lower-risk outpatients with subsegmental pulmonary embolism, few were eligible for structured surveillance, and only a small proportion of eligible patients underwent surveillance despite the CHEST guideline. If forthcoming trials find surveillance safe and effective, substantial uptake into clinical practice may require more than passive diffusion.

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Section: Resultsmentioning

confidence: 99%