Things We Do for No Reason: Routine Echocardiography in Hemodynamically Stable Patients with Acute Pulmonary Embolism

Abstract

Inspired by the ABIM Foundation's Choosing Wisely ® campaign, the "Things We Do for No Reason" (TWDFNR) series reviews practices that have become common parts of hospital care but may provide little value to our patients. Practices reviewed in the TWDFNR series do not represent "black and white" conclusions or clinical practice standards but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion. CLINICAL SCENARIOA 28 year-old woman presents to the emergency department with acute onset bilateral chest pain and dyspnea. She has a respiratory rate of 28, a heart rate of 106, blood pressure of 110/65 mm Hg, and pulse oximetry of 92% saturation on room air. She has no history of cardiac or pulmonary disease and no personal history of venous thromboembolism. She takes an estrogen-containing oral contraceptive. On examination, she has no jugular venous distention, normal cardiac tones without murmur, and no lower extremity swelling. D-dimer is elevated at 3.4 mg/L (normal < 0.5 mg/L), and she undergoes computed tomography (CT) of the chest, which demonstrates acute segmental pulmonary emboli (PE) in the right upper and middle lobes as well as multiple bilateral subsegmental PEs. The CT suggests right ventricular dysfunction (RVD), and her troponin T is 0.06 ng/mL (normal < 0.01 ng/mL). Bilateral lower extremity venous Doppler ultrasonography demonstrates no acute thrombus.

Treatment of Inpatient Asymptomatic Hypertension: Not a Call to Act but to Think

“…While both groups engaged physicians and nurses as primary stakeholders, Pasik et al 10 worked to further expand nursing staff roles by empowering them to assess for underlying causes of hypertension, such as pain or anxiety, as well as end-organ damage via specific guided algorithms prior to contacting physicians. In doing so, they reduced intravenous antihypertensive use by 60% during the postintervention period, with a proportional reduction in adverse events.…”

“…To address this limitation, the authors followed a group of 111 patients who had elevated hypertension but did not receive intravenous antihypertensives and found no adverse outcomes. 10 Because both studies were retrospective in nature, they were subject to biases from providers choosing intravenous antihypertensives for reasons that were neither captured by their datasets nor adjusted for. Additionally, neither study reported downstream impacts such as an increase in symptomatic hypertensive episodes or more rare events such as kidney injury, stroke, or myocardial infarction.…”

“…Given that guidelines discourage using intravenous antihypertensives, why were the efforts of Jacobs et al 9 and Pasik et al 10 needed in the first place? In a recent installment of Choosing Wisely: Things We Do For No Reason, Breu et al 11 cite two primary reasons: first, providers have unfounded fears that asymptomatic hypertension will quickly progress to cause organ damage; second, providers lack understanding of the potential harms from overtreatment.…”