Risk for Recurrent Venous Thromboembolism in Patients With Subsegmental Pulmonary Embolism Managed Without Anticoagulation

Gal, Grégoire Le; Kovacs, Michael J.; Bertoletti, Laurent; Couturaud, Francis; Dennie, Carole; Hirsch, Andrew; Huisman, Menno V.; Klok, Frederikus A.; Kraaijpoel, Noémie; Mallick, Ranjeeta; Pecarskie, Amanda; Peña, Elena; Phillips, Penny; Pichon, Isabelle; Ramsay, Tim; Righini, Marc; Rodger, Marc; Roy, Pierre‐Marie; Sanchez, Olivier; Schmidt, Jeannot; Schulman, Sam; Shivakumar, S; Trinh-Duc, Albert; Verdet, R; Vinsonneau, Ulric; Wells, Philip S.; Wu, Cynthia; Yeo, Erik; Carrier, Marc; Investigators, Sspe

doi:10.7326/m21-2981

Cited by 42 publications

(40 citation statements)

References 20 publications

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“…A prospective cohort study25 enrolling 292 patients diagnosed with SSPE (without cancer) found 28 (9.6%) had DVT at baseline or on repeat US a week later. Among 266 patients (without DVT at baseline or 1 week) managed without anticoagulation, 3.1% (95% CI 1.6 to 6.1) were diagnosed with recurrent VTE within 90 days 26. This first prospective study only supports withholding anticoagulation for all patients with SSPE with normal serial bilateral leg ultrasound, although shared decision making with the patient would be necessary to withhold anticoagulation.…”

Section: Management Of Subsegmental Pementioning

confidence: 83%

Pulmonary embolism management in the emergency department: part 2

et al. 2022

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Pulmonary embolism (PE) can present with a range of severity. Prognostic risk stratification is important for efficacious and safe management. This second of two review articles discusses the management of high-, intermediate- and low-risk PE. We discuss strategies to identify patients suitable for urgent outpatient care in addition to identification of patients who would benefit from thrombolysis. We discuss specific subgroups of patients where optimal treatment differs from the usual approach and identify emerging management paradigms exploring new therapies and subgroups.

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Section: Management Of Subsegmental Pementioning

confidence: 83%

Pulmonary embolism management in the emergency department: part 2

et al. 2022

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“…In contrast, Sun et al showed that in patients with lung cancer with reported iPE, untreated iPE was associated with worse overall survival [ 2 ], and previous studies have shown a comparable recurrent VTE risk for subsegmental iPE compared to more proximal iPE [ 15 , 16 ]. In addition, in a prospective management study on non-cancer patients with isolated subsegmental PE and without DVT who did not receive anticoagulant treatment, during the 90-day follow-up period the cumulative incidence of recurrent VTE was 3.1% (2.1% for a single subsegmental PE and 5.7% for multiple subsegmental PE), which was higher than anticipated [ 17 ].…”

Section: Discussionmentioning

confidence: 99%

Incidental pulmonary embolism in patients with cancer: prevalence, underdiagnosis and evaluation of an AI algorithm for automatic detection of pulmonary embolism

2022

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Objectives To assess the prevalence of reported and unreported incidental pulmonary embolism (iPE) in patients with cancer, and to evaluate an artificial intelligence (AI) algorithm for automatic detection of iPE. Methods Retrospective cohort study on patients with cancer with an elective CT study including the chest between 2018-07-01 and 2019-06-30. All study reports and images were reviewed to identify reported and unreported iPE and were processed by the AI algorithm. Results One thousand sixty-nine patients (1892 studies) were included. Per study, iPE was present in 75 studies (4.0%), of which 16 (21.3%) were reported. Unreported iPE had a significantly lower number of involved vessels compared to reported iPE, with a median of 2 (interquartile range, IQR, 1–4) versus 5 (IQR 3–9.75), p < 0.001. There were no significant differences in age, cancer type, or attenuation of the main pulmonary artery. The AI algorithm correctly identified 68 of 75 iPE, with 3 false positives (sensitivity 90.7%, specificity 99.8%, PPV 95.6%, NPV 99.6%). False negatives occurred in cases with 1–3 involved vessels. Of the unreported iPE, 32/59 (54.2%) were proximal to the subsegmental arteries. Conclusion In patients with cancer, the prevalence of iPE was 4.0%, of which only 21% were reported. Greater than 50% of unreported iPE were proximal to the subsegmental arteries. The AI algorithm had a very high sensitivity and specificity with only three false positives, with the potential to increase the detection rate of iPE. Key Points • In a retrospective single-center study on patients with cancer, unreported iPE were common, with the majority lying proximal to the subsegmental arteries. • The evaluated AI algorithm had a very high sensitivity and specificity, so has the potential to increase the detection rate of iPE.

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“…It was noted even in the original derivation study that the increased VTE events among lymphoma patients were driven by the incidental PEs noted on surveillance scans post‐transplant to assess residual disease. However, since even low‐risk subsegmental PE had a higher‐than‐expected rate of recurrent VTE, 19 these events should be considered for treatment. Finally, the association between increased weight and VTE among cancer patients tends to be very small and likely depends on the cohort population average weight and cut‐off 20 .…”

Section: Discussionmentioning

confidence: 99%

External validation of the HIGH‐2‐LOW model: A predictive score for venous thromboembolism after allogeneic transplant

Martens

Nguyen

et al. 2022

American J Hematol

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In patients undergoing hematopoietic cell transplantation (HCT), venous thromboembolism (VTE) remains a serious complication that lacks validated risk assessment models (RAMs) to guide thromboprophylaxis. To address this dilemma, we performed a temporal and external validation study of the recently derived HIGH‐2‐LOW RAM. We selected adult patients undergoing allogeneic HCT from Fred Hutchinson Cancer Research Center (FHCRC) and MD Anderson Cancer Center (MDACC). Patients who died, received anticoagulation, or did not engraft platelets by day 30 were excluded. Primary outcomes were defined as overall VTE and pulmonary embolism ± lower‐extremity deep venous thromboembolism (PE/LE‐DVT) by day 180. Covariates were weighted according to the original model, except that grade 2–4 GVHD was substituted for grade 3–4. Discrimination and calibration were assessed. A total of 765 patients from FHCRC and 954 patients from MDACC were included. Incident VTE by day 180 was 5.1% at FHCRC and 6.8% at MDACC. The HIGH‐2‐LOW score had a c‐statistic of 0.67 (0.59–0.75) for VTE and 0.75 (0.64–0.81) for PE/LE‐DVT at FHCRC and 0.62 (0.55–0.70) for VTE and 0.70 (0.56–0.83) for PE/LE‐DVT at MDACC. Twenty‐five percent and 23% of patients were classified as high risk (2+ points) in the two cohorts, respectively. High versus low‐risk was associated with odds ratio (OR) of 2.80 (1.46–5.38) for VTE and 4.21 (1.82–9.77) for PE/LE‐DVT at FHCRC and OR of 3.54 (2.12–5.91) for VTE and 6.82 (2.30–20.16) for PE‐LE‐DVT at MDACC. The HIGH‐2‐LOW RAM identified allogeneic HCT recipients at high risk for VTE in both validation cohorts. It can improve evidence‐based decision‐making for thromboprophylaxis post‐transplant.

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Risk for Recurrent Venous Thromboembolism in Patients With Subsegmental Pulmonary Embolism Managed Without Anticoagulation

Cited by 42 publications

References 20 publications

Pulmonary embolism management in the emergency department: part 2

Pulmonary embolism management in the emergency department: part 2

Incidental pulmonary embolism in patients with cancer: prevalence, underdiagnosis and evaluation of an AI algorithm for automatic detection of pulmonary embolism

External validation of the HIGH‐2‐LOW model: A predictive score for venous thromboembolism after allogeneic transplant

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