Emergency physician performed tricuspid annular plane systolic excursion in the evaluation of suspected pulmonary embolism

Daley, James M.; Grotberg, John C.; Pare, Joseph R.; Medoro, Amanda; Liu, Rachel; Hall, M. Kennedy; Taylor, Andrew; Moore, Christopher L.

doi:10.1016/j.ajem.2016.10.018

Cited by 46 publications

(54 citation statements)

References 30 publications

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“…A recent systematic review and meta‐analysis concluded that the overall sensitivity of FOCUS for PE is 53% (95% confidence interval [CI] = 45% to 61%) . However, ED patients with tachycardia who have a PE are more likely to show signs of RVD on FOCUS . RVD occurs in between 30% and 70% of patients with PE, and the absence of RVD in patients with hemodynamic compromise makes PE an unlikely etiology .…”

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confidence: 99%

“…However, ED patients with tachycardia who have a PE are more likely to show signs of RVD on FOCUS . RVD occurs in between 30% and 70% of patients with PE, and the absence of RVD in patients with hemodynamic compromise makes PE an unlikely etiology . EP‐performed FOCUS has been shown to be effective in detecting findings of RVD .…”

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confidence: 99%

“…RVD occurs in between 30% and 70% of patients with PE, and the absence of RVD in patients with hemodynamic compromise makes PE an unlikely etiology . EP‐performed FOCUS has been shown to be effective in detecting findings of RVD . Typical findings of RVD on FOCUS include right ventricular dilation, the presence of McConnell's sign, septal flattening, and tricuspid regurgitation (with regurgitant jet velocity on continuous‐wave Doppler > 2.6 m/sec)…”

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confidence: 99%

“…Recent literature has demonstrated that a less commonly utilized measure of RVD known as tricuspid annular plane systolic excursion (TAPSE) is more sensitive for the diagnosis of PE than other signs, is relatively easy to perform, and may be more reproducible as an objective measurement . TAPSE assesses for RVD by using M‐mode to measure the dynamic movement of the tricuspid valve annulus over the course of a contraction (Figure ) .…”

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confidence: 99%

“…TAPSE assesses for RVD by using M‐mode to measure the dynamic movement of the tricuspid valve annulus over the course of a contraction (Figure ) . Any value over 1.7 cm is typically considered normal, while any value below 1.7 cm is considered indicative of RVD . TAPSE correlates well with other modalities that measure RVD and has been shown to have high degrees of inter‐rater reliability among cardiologists and EPs with experience in FOCUS …”

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confidence: 99%

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Increased Sensitivity of Focused Cardiac Ultrasound for Pulmonary Embolism in Emergency Department Patients With Abnormal Vital Signs

Daley

Dwyer

Grunwald

et al. 2019

Academic Emergency Medicine

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Background Focused cardiac ultrasound (FOCUS) is insensitive for pulmonary embolism (PE). Theoretically, when a clot is large enough to cause vital sign abnormalities, it is more likely to show signs of right ventricular dysfunction on FOCUS, although this has not been well quantified. A rapid bedside test that could quickly and reliably exclude PE in patients with abnormal vital signs could be of high utility in emergency department (ED) patients. We hypothesized that in patients with tachycardia or hypotension, the sensitivity of FOCUS for PE would increase substantially. Methods We performed a prospective observational multicenter cohort study involving a convenience sample of patients from six urban academic EDs. Patients suspected to have PE with tachycardia (heart rate [HR] ≥ 100 beats/min) or hypotension (systolic blood pressure [sBP] < 90 mm Hg) underwent FOCUS before computed tomography angiography (CTA). FOCUS included assessment for right ventricular dilation, McConnell's sign, septal flattening, tricuspid regurgitation, and tricuspid annular plane systolic excursion. If any of these were abnormal, FOCUS was considered positive, while if all were normal, FOCUS was considered negative. We a priori planned a subgroup analysis of all patients with a HR ≥ 110 beats/min (regardless of their sBP). We then determined the diagnostic test characteristics of FOCUS for PE in the entire patient population and in the predefined subgroup, based on CTA as the criterion standard. Inter‐rater reliability of FOCUS was determined by blinded review of images by an emergency physician with fellowship training in ultrasound. Results A total of 143 subjects were assessed for enrollment and 136 were enrolled; four were excluded because they were non–English‐speaking and three because of inability to obtain any FOCUS windows. The mean (±SD) age of enrolled subjects was 56 (±7) years, mean (±SD) HR was 114 (±12) beats/min, and 37 (27.2%) subjects were diagnosed with PE on CTA. In all subjects, FOCUS was 92% (95% confidence interval [CI] = 78% to 98%) sensitive and 64% specific (95% CI = 53% to 73%) for PE. In the subgroup of 98 subjects with a HR ≥ 110 beats/min, FOCUS was 100% sensitive (95% CI = 88% to 100%) and 63% specific (95% CI = 51% to 74%) for PE. There was substantial interobserver agreement for FOCUS (κ = 1.0, 95% CI = 0.31 to 1.0). Conclusions A negative FOCUS examination may significantly lower the likelihood of the diagnosis of PE in most patients who are suspected of PE and have abnormal vital signs. This was especially true in those patients with a HR ≥ 110 beats/min. Our results suggest that FOCUS can be an important tool in the initial evaluation of ED patients with suspected PE and abnormal vital signs.

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confidence: 99%

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confidence: 99%

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confidence: 99%

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confidence: 99%

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confidence: 99%

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Increased Sensitivity of Focused Cardiac Ultrasound for Pulmonary Embolism in Emergency Department Patients With Abnormal Vital Signs

Daley

Dwyer

Grunwald

et al. 2019

Academic Emergency Medicine

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Predictors of reduced cardiac index in patients with acute submassive pulmonary embolism

Ammari

Al-Sarie

et al. 2020

Cathet Cardio Intervent

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Objectives Determine the baseline clinical, laboratory, and echocardiographic values that predict reduced cardiac index (CI) among subjects with acute submassive pulmonary embolism (PE). Background Submassive PE represents a large portion of acute PE population and there is controversy regarding optimal treatment strategies for these patients. There is significant heterogeneity within the submassive PE population and further refinement of risk stratification may aid clinical decision‐making. Methods We identified subjects with normotensive acute PE who underwent echocardiogram and right heart catheterization (RHC) prior to catheter‐directed thrombolysis (CDT). We sought to determine the predictors of reduced CI, defined as CI < 2.2 L min‐1m‐2. Results Thirty‐two subjects met the inclusion criteria and 41% had reduced CI. Baseline variables did not distinguish subjects with reduced versus normal CI. Brain natriuretic peptide (BNP) was significantly different between the reduced versus normal CI groups (BNP 440 vs. 160 pg/ml, p = .004, respectively). Univariate logistic regression identified BNP, right ventricular (RV):left ventricular (LV) diameter ratio, tricuspid annular plane systolic excursion (TAPSE), and right ventricular systolic pressure as predictors of reduced CI. In a multivariate logistic regression model, only TAPSE was an independent predictor of reduced CI. ROC curve analysis identified the following optimal cut points for prediction of reduced CI: BNP > 216 pg/ml, RV:LV ratio > 1.41, or TAPSE <1.6 cm. Conclusions Almost half of subjects with acute submassive PE have reduced CI, despite normal systemic blood pressure. Optimal cut points for BNP, RV:LV ratio, and TAPSE were identified to predict reduced CI among patients with acute PE. These findings may aid in clinical decision‐making and risk stratification of patients with acute submassive PE.

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Tricuspid annular plane of systolic excursion to prognosticate acute pulmonary symptomatic embolism (TAPSEPAPSE study)

Lahham

Fox

Thompson

et al. 2018

J of Ultrasound Medicine

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Emergency physician performed tricuspid annular plane systolic excursion in the evaluation of suspected pulmonary embolism

Cited by 46 publications

References 30 publications

Increased Sensitivity of Focused Cardiac Ultrasound for Pulmonary Embolism in Emergency Department Patients With Abnormal Vital Signs

Increased Sensitivity of Focused Cardiac Ultrasound for Pulmonary Embolism in Emergency Department Patients With Abnormal Vital Signs

Predictors of reduced cardiac index in patients with acute submassive pulmonary embolism

Tricuspid annular plane of systolic excursion to prognosticate acute pulmonary symptomatic embolism (TAPSEPAPSE study)

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