How to Combat Over-Testing for Patients Suspected of Pulmonary Embolism: A Narrative Review.

The diagnosis of PE remains difficult in 2023 because the signs and symptoms are not sensible nor specific. The consequences of potential diagnostic errors can be dramatic, whether by default or by excess. Furthermore, the achievement of a simple diagnostic strategy, based on clinical probability assessment, D-dimer measurement and computed tomography pulmonary angiography (CTPA) leads to a new challenge for PE diagnosis: over-testing. Indeed, since the 2000s, the wide availability of CTPA resulted in a major increase in investigations with a mod I confirm erate increase in PE diagnosis, without any notable improvement in patient outcomes. Quite the contrary, the complications of anticoagulation for PE increased significantly, and the long-term consequences of imaging diagnostic radiation is an important concern, especially the risk of breast cancer for young women. As a result, several strategies have been proposed to fight over-testing. They are mostly based on defining a subgroup of patients for whom no specific exam should be required to rule-out PE and adjusting the D-dimer cutoff to allow the exclusion of PE without performing CTPA. This narrative review presents the advantages and limitations of these different strategies as well as the perspective in PE diagnosis.

Assessing the clinical probability of pulmonary embolism during pregnancy: The Pregnancy-Adapted Geneva (PAG) score.

BACKGROUND: The diagnosis of pulmonary embolism (PE) in pregnant women represents an ongoing challenge. As in the general population, the first step in pregnant women with suspected PE consists of assessing clinical pre-test probability (PTP). However, no dedicated clinical decision rule has been developed in this population. OBJECTIVE: To propose a new version of the Geneva score adapted to pregnant women with suspected PE. METHODS: Data from a multicenter, prospective management outcome study including 395 women with suspected PE, in whom PTP was assessed using the Geneva score, were used. We first removed items which were present in none of the patients (cancer, age >65 years). Receiver operating characteristic (ROC) curve analysis was then performed for quantitative variables and the optimal threshold defined. The obtained Pregnancy-Adapted Geneva Score (PAG Score) comprised seven items, including an age 40 years or older and a heart rate >110 beats per minute. RESULTS: The PAG Score showed a high discriminative power to identify patients with a low, intermediate, or high PTP, associated with increasing prevalence of PE, 2.3%, 11.6%, and 61.5%, respectively. The ROC curves showed an area under the curve of 0.795 for the PAG Score compared to 0.684 for the Geneva score. CONCLUSION: In pregnant women with suspected PE, the PAG Score shows a high discriminative power to identify patients at low, intermediate, or high PTP. It has the strength of being a fully objective decision rule, is clinically relevant, easy to compute, and should now be tested in a prospective outcome study.

Thromboembolic risk stratification by TRiP(cast) score to rationalise thromboprophylaxis in patients with lower leg trauma requiring immobilisation: a study protocol of the casting stepped-wedge cluster randomised trial.

INTRODUCTION: Patients with lower limb trauma requiring orthopaedic immobilisation may be at risk of venous thromboembolism but opinions differ about who may benefit from thromboprophylactic anticoagulant treatment.The aim of this CASTING study is to demonstrate the safety of thromboprophylaxis based on the Thrombosis Risk Prediction for patients with cast immobilisation (TRiP(cast) score with regards to the 3-month incidence of symptomatic venous thromboembolism events in low-risk patients not receiving thromboprophylaxis, as well as the usefulness of this strategy on the rate of patients receiving anticoagulant treatment in comparison to current practice. METHODS AND ANALYSIS: CASTING will be a stepped-wedge cluster randomised controlled clinical trial, performed in 15 emergency departments in France and Belgium. With their informed consent, outpatients admitted to one of the participating emergency departments for a lower limb trauma requiring orthopaedic immobilisation without surgery will be included. All centres will begin the trial with the 'observational period' and, every 2 weeks, 1 centre will be randomly assigned to switch to the 'interventional period' and to apply the TRiP(cast) score, in which only patients with a score ≥7 will receive thromboprophylactic anticoagulant treatment. The primary endpoint is the rate of clinical thromboembolic events within 90 days following the inclusion of low-risk patients not receiving thromboprophylaxis. ETHICS AND DISSEMINATION: The protocol has been approved by the Comité de Protection des Personnes Sud I (Ethics Review ID-RCB: 2019-A01829-48) for France and the Comité d'éthique hôpital-facultaire Saint Luc (N° B403201941338) for Belgium. It is carried out in accordance with the Declaration of Helsinki and Good Clinical Practice guidelines. The findings of this study will be disseminated in peer-reviewed journals and at scientific conferences. TRIAL REGISTRATION NUMBER: NCT04064489.

Validation of risk assessment models predicting venous thromboembolism in acutely ill medical inpatients: A cohort study.

BACKGROUND: Because hospital-acquired venous thromboembolism (VTE) represents a frequent cause of preventable deaths in medical inpatients, identifying at-risk patients requiring thromboprophylaxis is critical. We aimed to externally assess the Caprini, IMPROVE, and Padua VTE risk scores and to compare their performance to advanced age as a stand-alone predictor. METHODS: We performed a retrospective analysis of patients prospectively enrolled in the PREVENU trial. Patients aged 40 years and older, hospitalized for at least 2 days on a medical ward were consecutively enrolled and followed for 3 months. Critical ill patients were not recruited. Patients diagnosed with VTE within 48 hours from admission, or receiving full dose anticoagulant treatment or who underwent surgery were excluded. All suspected VTE and deaths occurring during the 3-month follow-up were adjudicated by an independent committee. The three scores were retrospectively assessed. Body mass index, needed for the Padua and Caprini scores, was missing in 44% of patients. RESULTS: Among 14 910 eligible patients, 14 660 were evaluable, of which 1.8% experienced symptomatic VTE or sudden unexplained death during the 3-month follow-up. The area under the receiver operating characteristic curves (AUC) were 0.60 (95% confidence interval [CI] 0.57-0.63), 0.63 (95% CI 0.60-0.66) and 0.64 (95% CI 0.61-0.67) for Caprini, IMPROVE, and Padua scores, respectively. None of these scores performed significantly better than advanced age as a single predictor (AUC 0.61, 95% CI 0.58-0.64). CONCLUSION: In our study, Caprini, IMPROVE, and Padua VTE risk scores have poor discriminative ability to identify not critically ill medical inpatients at risk of VTE, and do not perform better than a risk evaluation based on patient's age alone.