Risk profile and clinical outcome of symptomatic subsegmental acute pulmonary embolism

Exter, Paul L. den; Es, Josien van; Klok, Frederikus A.; Kroft, Lucia J.M.; Kruip, Marieke J.H.A.; Kamphuisen, Pieter Willem; Büller, Harry R.; Huisman, Menno V.

doi:10.1182/blood-2013-04-497545

Cited by 154 publications

(113 citation statements)

References 22 publications

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“…Also, when compared with patients without PE, patients with subsegmental PE were at an increased risk of VTE during follow-up (hazard ratio, 3.8; 95% CI, 1.3-11.1). The study indicates that in contrast to the common belief that subsegmental PE represents a benign subset of VTE, patients with symptomatic subsegmental PE have comparable prognosis as patients with segmental or more proximal PE regarding short-term clinical course (34). Thus, subsegmental PE is clinically relevant and should be reported when present.…”

Section: Ct Diagnosis Of Subsegmental Pementioning

confidence: 58%

The role of computed tomography in the diagnosis of acute and chronic pulmonary embolism

Doğan

A²,

Geleijins³

et al. 2015

Diagn Interv Radiol

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A cute pulmonary embolism (PE) is the third most common cardiovascular condition, after coronary artery disease and stroke (1). Due to lack of specific sets of symptoms that accurately predict or exclude the diagnosis of acute PE, the diagnosis strongly relies on noninvasive imaging techniques. Diagnostic strategies for evaluating PE have undergone important changes over the past decades (2). Due to rapid technical advances in speed and spatial resolution, the utility of computed tomography (CT) angiography has been recognized in vascular imaging. Particularly, after the development of multidetector row CT in 1998 (3), CT pulmonary angiography (CTPA) has become the imaging method of choice in the diagnosis of acute PE (4). CTPA has advantages over conventional invasive X-ray pulmonary angiography and nuclear ventilation-perfusion (V/Q) imaging. CT is a widely available, fast and noninvasive technique, has the capability to directly visualize emboli, and may provide alternative diagnoses (4).Despite adequate diagnosis and anticoagulant therapy, death rate after a diagnosis of acute PE is still 8%-15% (5, 6). The prognosis of acute PE mainly depends on residual pulmonary circulation and the severity of right ventricular (RV) dysfunction (7). Recent studies have shown that CT permits the assessment of acute right-sided heart failure. Furthermore, CT can predict adverse clinical outcome by using the RV/left ventricular (LV) diameter ratio (8, 9) or RV ejection fraction in patients with PE (10).The aim of this review is to discuss the developments of CT in PE diagnosis, and to analyze the added value of CT in estimating PE severity and prognosis. Furthermore, CT findings of chronic thromboembolic pulmonary arterial hypertension (CTEPH) as a complication of acute PE will be discussed. CT developments in PE diagnosisHistorically, pulmonary angiography and nuclear planar V/Q-imaging were the main imaging methods used for diagnosing PE. Both methods have recognized limitations. Pulmonary angiography has previously been regarded as reference standard, but the method CHEST IMAGING REVIEW ABSTRACT Pulmonary embolism (PE) is a potentially life threatening condition requiring adequate diagnosis and treatment. Computed tomography pulmonary angiography (CTPA) is excellent for including and excluding PE, therefore CT is the first-choice diagnostic imaging technique in patients suspected of having acute PE. Due to its wide availability and low invasiveness, CTPA tends to be overused. Correct implementation of clinical decision rules in diagnostic workup for PE improves adequate use of CT. Also, CT adds prognostic value by evaluating right ventricular (RV) function. CT-assessed RV dysfunction and to lesser extent central emboli location predicts PE-related mortality in normotensive and hypotensive patients, while PE embolic obstruction index has limited prognostic value. Simple RV/left ventricular (LV) diameter ratio measures >1.0 already predict risk for adverse outcome, whereas ratios <1.0 can safely exclude adverse outcome. Con...

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Section: Ct Diagnosis Of Subsegmental Pementioning

confidence: 58%

The role of computed tomography in the diagnosis of acute and chronic pulmonary embolism

Doğan

A²,

Geleijins³

et al. 2015

Diagn Interv Radiol

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“…Clinical data have suggested that treating patients with these presentations with anticoagulants may not be necessary in the absence of cardiopulmonary compromise, concurrent DVT or persistent risk factors for recurrent VTE [68,69]. However, a recent analysis of 3728 patients with clinically suspected PE found a similar prevalence of VTE risk factors and 3-month risk of recurrent VTE and mortality in patients with subsegmental PE as in those with more proximal PE [70], suggesting that these presentations should be taken seriously, at least when symptoms or other factors are present. These patients could be candidates for outpatient treatment, particularly now that direct OAC treatment is an option.…”

Section: Inpatient Versus Outpatient Management Of Pementioning

confidence: 94%

Developments in the management and treatment of pulmonary embolism

Limbrey

Howard

2015

Eur Respir Rev

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Pulmonary embolism (PE) is a serious and costly disease for patients and healthcare systems. Guidelines emphasise the importance of differentiating between patients who are at high risk of mortality (those with shock and/or hypotension), who may be candidates for thrombolytic therapy or surgery, and those with less severe presentations. Recent clinical studies and guidelines have focused particularly on risk stratification of intermediate-risk patients. Although the use of thrombolysis has been investigated in these patients, anticoagulation remains the standard treatment approach. Individual risk stratification directs initial treatment. Rates of recurrence differ between subgroups of patients with PE; therefore, a review of provoking factors, along with the risks of morbidity and bleeding, guides the duration of ongoing anticoagulation. The direct oral anticoagulants have shown similar efficacy and, in some cases, reduced major bleeding compared with standard approaches for acute treatment. They also offer the potential to reduce the burden on patients and outpatient services in the post-hospital phase. Rivaroxaban, dabigatran and apixaban have been shown to reduce the risk of recurrent venous thromboembolism versus placebo, when given for >12 months. Patients receiving direct oral anticoagulants do not require regular coagulation monitoring, but follow-up, ideally in a specialist PE clinic in consultation with primary care providers, is recommended. @ERSpublications Direct oral anticoagulants have the potential to improve management of patients with pulmonary embolism http://ow.ly/NV7K6

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“…В одном из последних ретроспективных исследований 2 когорт больных с подозрением на ТЭЛА при субсегментар ной и более проксимальной ТЭЛА получены одина ковые результаты (частота рецидивов в течение 3 мес. и летальность), которые во многом зависли от сопутствующей патологии [205]. Определение суб сегментарной ТЭЛА не стандартизовано, и одиноч ный субсегментарный дефект визуализации, скорее всего, не имеет такого же клинического значения, как множественные субсегментарные тромбы.…”

Section: нерешенные вопросыunclassified

Pulmonary embolism: clinical guidelines of European Society of Cardiology (2014).The Task Force of the European Society of Cardiology for diagnosis and management of pulmonary embolism

Редакционная¹

2015

Pulʹmonologiâ (Mosk.)

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РезюмеВ данных Клинических рекомендациях суммированы все современные доказательства по диагностике и лечению тромбоэмболии легочной артерии (ТЭЛА). В отличие от предыдущей версии рекомендаций, в данном документе представлены упрощенные варианты клинических прогностических шкал, подробно рассмотрена стратификация риска летального исхода, включая промежуточные степени риска, представлены новые подходы к АКТ, в т. ч. системному тромболизису и катетерным методам лечения, терапии антагонистом витамина К, определено место новых пероральных антикоагулянтов в терапии ТЭЛА. Ключевые слова: рекомендации, тромбоэмболия легочной артерии, венозный тромбоз, шок, гипотензия, торакалгия, одышка, сердеч ная недостаточность, диагностика, антикоагулянты, тромболизис. SummaryThese clinical recommendations summarized currently available evidence on diagnosis and management of patients with pulmonary embolism. When compared to previous version of recommendations, this document has introduced simplified clinical prognostic scales and a new risk stratifi cation system including intermediate risk. Novel approach to anticoagulant therapy have been also reviewed including systemic thrombolysis, catheter directed treatment, vitamin K antagonists and new oral anticoagulants. Key words: recommendations, pulmonary embolism, venous thromboembolism, shock, hypotension, chest pain, dyspnea, heart failure, diagnosis, anticoagulants, thrombolysis.Тромбоэмболия легочной артерии: клинические рекомендации Европейского общества кардиологов (2014) 526Пульмонология. 2015; 25 (5): 525-552 возникавших в ходе работы над Рекомендациями, надлежало информировать ЕОК и вносить соответ ствующие поправки. Финансирование Рабочей груп пы проводилось за счет средств ЕОК полностью, без участия представителей медицинской промышлен ности.Комитетом ЕОК по Практическим рекомендаци ям проведены наблюдение за процессом подготовки новых Клинических рекомендаций и его координа ция. Члены Комитета также несли ответственность за утверждение новых Клинических рекомендаций. Клинические рекомендации ЕОК активно проана лизированы Комитетом по Практическим рекомен дациям и внешними экспертами. После соответст вующих поправок Рекомендации были одобрены всеми экспертами Рабочей группы. Окончательный документ был утвержден Комитетом по Практичес ким рекомендациям для публикации в журнале European Heart Journal.Задача написания Клинических рекомендаций ЕОК заключается не только в объединении результа тов исследований последних лет, но также и в разра ботке образовательных методик и программ внедре ния Рекомендаций в практическое здравоохранение.Для практического использования Рекоменда ций готовится их краткая («карманная») версия, а также слайды, буклеты с ключевыми положения ми, листовки для неспециалистов и электронная версия для смартфонов и других гаджетов (сокра щенные варианты); с полным текст Рекомендаций опубликован на сайте ЕОК и находится в свободном доступе. Национальным обществам рекомендуется утверждать, переводить на национальные языки и внедрять Клинические рекоме...

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Risk profile and clinical outcome of symptomatic subsegmental acute pulmonary embolism

Abstract: Key Points Patients with subsegmental PE appear to mimic those with more proximally located PE regarding their VTE risk profile and clinical outcome. Patients with subsegmental PE significantly differ from patients without PE in terms of both VTE risk profile and clinical outcome.

Cited by 154 publications

References 22 publications

The role of computed tomography in the diagnosis of acute and chronic pulmonary embolism

The role of computed tomography in the diagnosis of acute and chronic pulmonary embolism

Developments in the management and treatment of pulmonary embolism

Pulmonary embolism: clinical guidelines of European Society of Cardiology (2014).The Task Force of the European Society of Cardiology for diagnosis and management of pulmonary embolism

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