PE: A New Approach to Low Risk Patients

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I presented this talk at the ACEM Annual Scientific Meeting 2014 – Monday 8/12/14

PE Talk ACEM ASM cover page

 

 

Mortality of Untreated PE

Calder KK, Herbert M, Henderson SO. The mortality of untreated pulmonary embolism in emergency department patients. Ann Emerg Med. 2005;45(3):302-10.

Stein PD, Hull RD, Raskob GE. Withholding treatment in patients with acute pulmonary embolism who have a high risk of bleeding and negative serial noninvasive leg tests. Am J Med. 2000;109(4):301-6.

Benefit of Treatment

Barritt DW, Jordan SC. Anticoagulant drugs in the treatment of pulmonary embolism. A controlled trial. Lancet. 1960;1(7138):1309-12.

Nielsen HK, Husted SE, Krusell LR, Fasting H, Charles P, Hansen HH. Silent pulmonary embolism in patients with deep venous thrombosis. Incidence and fate in a randomized, controlled trial of anticoagulation versus no anticoagulation. J Intern Med. 1994;235(5):457-61.

Risk of Treatment

Carrier M, Le Gal G, Wells PS, Rodger MA. Systematic review: case-fatality rates of recurrent venous thromboembolism and major bleeding events among patients treated for venous thromboembolism. Ann Intern Med. 2010;152(9):578-89.

Risk of Contrast

Mitchell AM, Jones AE, Tumlin JA, Kline JA. Incidence of contrast-induced nephropathy after contrast-enhanced computed tomography in the outpatient setting. Clin J Am Soc Nephrol. 2010;5(1):4-9.

Newhouse JH, RoyChoudhury A. Quantitating contrast medium-induced nephropathy: controlling the controls. Radiology. 2013;267(1):4-8.

McDonald JS, McDonald RJ, Comin J, Williamson EE, Katzberg RW, Murad MH, et al. Frequency of acute kidney injury following intravenous contrast medium administration: a systematic review and meta-analysis. Radiology. 2013;267(1):119-28.

McDonald RJ, McDonald JS, Bida JP, Carter RE, Fleming CJ, Misra S, et al. Intravenous contrast material-induced nephropathy: causal or coincident phenomenon? Radiology. 2013;267(1):106-18.

Davenport MS, Khalatbari S, Dillman JR, Cohan RH, Caoili EM, Ellis JH. Contrast material-induced nephrotoxicity and intravenous low-osmolality iodinated contrast material. Radiology. 2013;267(1):94-105.

Accuracy of CTPA

Stein PD, Woodard PK, Weg JG, Wakefield TW, Tapson VF, Sostman HD, et al. Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II investigators. Am J Med. 2006;119(12):1048-55.

Test Threshold

Kline JA, Mitchell AM, Kabrhel C, Richman PB, Courtney DM. Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism. J Thromb Haemost. 2004;2(8):1247-55.

Lessler AL PJ. In Reply Ann Emerg Med 2010;56(5):587.

Summarising Risks v Harms of Testing 

Newman DH, Schriger DL. Rethinking testing for pulmonary embolism: less is more. Ann Emerg Med. 2011;57(6):622-7 e3.

PERC Rule

Singh B, Mommer SK, Erwin PJ, Mascarenhas SS, Parsaik AK. Pulmonary embolism rule-out criteria (PERC) in pulmonary embolism–revisited: a systematic review and meta-analysis. Emerg Med J. 2013;30(9):701-6.

Fesmire FM, Brown MD, Espinosa JA, Shih RD, Silvers SM, Wolf SJ, et al. Critical issues in the evaluation and management of adult patients presenting to the emergency department with suspected pulmonary embolism. Ann Emerg Med. 2011;57(6):628-52 e75.

Clinical Prediction Rule Meta-analayses

Ceriani E, Combescure C, Le Gal G, Nendaz M, Perneger T, Bounameaux H, et al. Clinical prediction rules for pulmonary embolism: a systematic review and meta-analysis. J Thromb Haemost. 2010;8(5):957-70.

Lucassen W, Geersing GJ, Erkens PM, Reitsma JB, Moons KG, Buller H, et al. Clinical decision rules for excluding pulmonary embolism: a meta-analysis. Ann Intern Med. 2011;155(7):448-60.

Patient Risk Tolerance

Davis MA, Keerbs A, Hoffman JR, Baraff LJ. Admission decisions in emergency department chest pain patients at low risk for myocardial infarction: patient versus physician preferences. Ann Emerg Med. 1996;28(6):606-11.

Flynn D, Knoedler MA, Hess EP, Murad MH, Erwin PJ, Montori VM, et al. Engaging patients in health care decisions in the emergency department through shared decision-making: a systematic review. Acad Emerg Med. 2012;19(8):959-67.

Geyer BC, Xu M, Kabrhel C. Patient preferences for testing for pulmonary embolism in the ED using a shared decision-making model. Am J Emerg Med. 2013.
10. Hess EP, Knoedler MA, Shah ND, Kline JA, Breslin M, Branda ME, et al. The chest pain choice decision aid: a randomized trial. Circ Cardiovasc Qual Outcomes. 2012;5(3):251-9.

Hess EP, Knoedler MA, Shah ND, Kline JA, Breslin M, Branda ME, et al. The chest pain choice decision aid: a randomized trial. Circ Cardiovasc Qual Outcomes. 2012;5(3):251-9.

Kramer MS, Etezadi-Amoli J, Ciampi A, Tange SM, Drummond KN, Mills EL, et al. Parents’ versus physicians’ values for clinical outcomes in young febrile children. Pediatrics. 1994;93(5):697-702.

 

 

6 thoughts on “PE: A New Approach to Low Risk Patients”

  1. Excellent talk Anand, our current practice has seemed pretty crazy to me for some time, we have as a group become obscessed with making a daignosis without thinking about the harm that that this may entail in many conditions

  3. Informative talk that will impact my assessment of patients. Thank you, however what about ‘softer’ adverse effects of Untreated PE such as long term decreased lung function rather than just mortality?

  4. thanks for the comments guys
    Yes Aaron, I agree the non-fatal risks of PE are indeed worth considering. The problem is that they then get treated equally in the TT calculation with other non-fatal risks that are more disabling, such as a non fatal ICH from anticoagulation. This means we are no longer comparing apples with apples mathematically. I’ve therefore restricted the calculation to mortality risk/benefits only. However if we still did choose to add the non-fatal risks/benefits into the calculation I find the TT actually increases even higher.

    Mark – I couldn’t agree more.

    Cheers

  5. Thanks for response and research anand, that’s interesting. Reminds me of a patient last year who sustained a trimalleolar fracture and flank haematoma in an mva. A ct abdomen had been ordered by trauma team and found an incidental small PE in basal lung fields (she was asymptomatic of it). Advice from haematology was that the only defensible action was to put on warfarin for 3 months despite our concerns. It would be great if this thinking and advice from the specialists could change if the risks really do outweigh the benefits…

  6. Great case highlighting how our blind faith in the completely unproven benefit of anticoagulation in PE, guides us to make such decisions despite significant competing risks of haemorrhage in this patient … and that’s leaving aside the entire lack of evidence for the benefit of treating incidental PE at all.
    Interesting to recall one of the autopsy studies I mentioned in the talk where 1 in 5 patients who died immediately from major trauma had incidental PE’s on autopsies suggesting they are frequent incidental benign findings.
    I wonder whether a more “defensible” action in such a case might be to discuss the pro’s and con’s with the patient and make a shared decision.

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