Low concordance between CTPA and echocardiography in identification of right ventricular strain in PERT patients with acute pulmonary embolism.

PURPOSE: Right ventricular strain (RVS) is used to risk stratify patients with acute pulmonary embolism (PE) and influence treatment decisions. Guidelines suggest that either computed tomography pulmonary angiography (CTPA) or transthoracic echocardiography (TTE) can be used to assess RVS. We sought to determine how often CTPA and TTE yield discordant results and to assess the test characteristics of CTPA compared to TTE. METHODS: We analyzed data from a single-center registry of PE cases severe enough to warrant activation of the hospital's Pulmonary Embolism Response Team (PERT). We defined RVS as a right ventricular to left ventricular ratio (RV/LV) ≥ 1 or radiologist's interpretation of RVS on CTPA or as the presence of either RV dilation, hypokinesis, or septal bowing on TTE. RESULTS: We included 554 patients in our analysis, of whom 333 (60%) had concordant RVS findings on CTPA and TTE. Using TTE as the reference standard, CTPA had a sensitivity of 95% (95% CI 92-97%) and a specificity of 4% (95% CI 2-8%) for identifying RVS. CONCLUSIONS: In a selected population of patients with acute PE for which PERT was activated, CTPA is highly sensitive but not specific for the detection of RVS when compared to TTE.

Calendar month variation in the diagnosis and severity of pulmonary embolism.

BACKGROUND: Pulmonary embolism (PE) is the third-leading cause of cardiovascular death in the United States, and several studies suggest PE shows seasonal variation. Variation in monthly PE diagnosis may be due to pathophysiologic factors or confounding/bias. However, severe PE may be less prone to diagnostic bias. To address this gap, we analyzed two registries from 1/2013-12/2018 with the aim of describing temporal trends in PE diagnosis and severity. METHODS: We performed a retrospective analysis of two existing databases containing: (1) consecutive patients diagnosed with PE in the emergency departments (EDs) of two large, urban teaching hospitals, and (2) severe PEs requiring PE Response Team (PERT) activation at one of the above hospitals. The primary outcome was to assess variation in PE diagnosis and severity by calendar month. Separate analysis of these two databases sought to control for workup bias by trainee experience across the academic year. One-way ANOVA and Poisson regression were performed to assess for cyclical variation across calendar months, using Stata v16.1. RESULTS: The PE diagnosis database contained 1324 patients over 36 months. One-way ANOVA did not reveal a statistically significant (p = 0.713) association between calendar month and PE number. The PERT activation database contained 1082 patients over 72 months. One-way ANOVA revealed a statistically significant (p = 0.024) association between calendar month and activations, repeated year-on-year. CONCLUSION: Our results indicate correlation between calendar month and PERT activation; however, this pattern was not observed for PE diagnoses. This finding warrants further investigation into the causes of calendar month variation of PERT activations.

Patient and operational factors that influence the decision to place an inferior vena cava filter in a pulmonary embolism response team.

OBJECTIVE: The use of inferior vena cava (IVC) filters is controversial. However, the procedure is widely performed for secondary prophylaxis in patients with severe pulmonary embolism (PE), including those treated by a PE response team (PERT). In this study, we analyzed patient factors associated with the clinical decision to place an IVC filter in PERT patients. METHODS: Data were collected on all Massachusetts General Hospital patients who had a PERT activation from October 1, 2012, to January 29, 2019. Data describing demographics, medical history, PE characteristics and treatment were collected at the time of PERT activation and prospectively for one year after PERT activation. Univariate and multivariable regression analyses were performed to determine factors associated with IVC filter placement. RESULTS: We identified 834 patients, of whom 91 (10.9%) had an IVC filter placed in the first 7 days after PERT activation. The majority of patients receiving an IVC filter were male (55/91 [60.4%]; P =.096) with a mean age of 65 ± 15.0 years. Patients who received an IVC filter were less likely to have had a PERT referral from the Emergency Department (ED) (41/544 [7.5%]; P < .001) and more likely to have been referred from the intensive care unit (24/107 [22.43%]; P ≤ .001) compared with a floor referral. Patients who presented with syncope (15/86 [17.4%]; P = .040), a history of recent trauma (12/41 [29.3%]; P < .001), intracranial hemorrhage (11/39 [28.2%]; P = .002), a recent surgery or invasive procedure (30/188 [16.0%]; P = .012), a recent surgery (29/160 [18.1%]; P = .001) and a recent hospitalization (38/250 [15.2%]; P = .009) were more likely to have an IVC filter placed. Patients receiving an IVC filter were also more likely to have evidence of right heart dysfunction on a computed tomography pulmonary angiogram (61/359 [17.0%]; P < .001) and an echocardiogram (26/144 [18.1%]; P = .003). Compared with patients without an IVC filter, the 30-day venous thromboembolism recurrence rate was higher (4.7% vs 11.0%) in patients with IVC filters (10/45 [22.2%]; P = .023). CONCLUSIONS: Factors associated with venous thromboembolism severity (eg, PERT referral from intensive care unit and right ventricular dysfunction) and an increased bleeding risk (eg, recent surgery or trauma) were associated with IVC filter placement among PERT patients.

Pulmonary embolism with clot in transit: An analysis of risk factors and outcomes.

OBJECTIVES: Clot in transit (CIT) represents a rare and life-threatening manifestation of venous thromboembolism of which we have limited understanding. This study describes the risk factors, clinical characteristics, and outcomes associated with the development of CIT as well as death following CIT diagnosis. METHODS: We analyzed patients enrolled in our institutional Pulmonary Embolism Response Team (PERT) registry and compared 57 patients who had a CIT to 608 pulmonary embolism (PE) patients who did not have a CIT. We performed univariate and multivariate logistic regression to identify factors associated with CIT (vs PE without CIT) among patients who had an echocardiogram, as well as factors associated with 7-day death after CIT diagnosis. RESULTS: CIT was present in (57) 8.6% of patients who had an echocardiogram. Multivariate analysis showed heart failure (OR 2.8, 95% CI 1.2-6.5, P = 0.01), a pre-existing central venous catheter (OR 2.5, 95% CI 1.1-5.7, P = 0.03), and hypotension (OR 2.1, 95% CI 1.1-3.7, P = 0.02) to be independently associated with CIT. All-cause mortality by 7 days was higher in CIT patients (12.5% vs 5.1%, P = 0.02). CIT patients who died were more likely to have presented with hemodynamic collapse (57.1% vs 14.0%, P = 0.02), mental status change (100% vs 22.0%, P < 0.001), and to be intubated (100% vs 36.0%, P = 0.001). CONCLUSIONS: The presence of heart failure, a central venous catheter, and hypotension should alert physicians to patients who may require an echocardiogram to diagnose CIT. The mortality of CIT is high, even relative to a population with severe PE.

Multicenter Implementation of a Novel Management Protocol Increases the Outpatient Treatment of Pulmonary Embolism and Deep Vein Thrombosis.

OBJECTIVE: The objective was to determine whether a protocol combining risk stratification, treatment with the direct-acting oral anticoagulant rivaroxaban, and defined follow-up is associated with a greater proportion of patients with venous thromboembolism (VTE) treated as outpatients, without hospital admission. METHODS: We performed a multicenter study of patients diagnosed with VTE (pulmonary embolism [PE] or deep vein thrombosis [DVT]) in two urban EDs, 18 months before and 18 months after implementation of an outpatient VTE treatment protocol. Patients with radiographically confirmed acute VTE were eligible. Our primary outcome was the proportion of VTE patients discharged from the ED or observation unit (i.e., without hospital admission). We performed subgroup analyses according to hospital, DVT and PE, and low-risk PE. We also assessed 7- and 30-day mortality, major bleeding, and returns to the ED. We compared proportions using chi-square and Fisher's exact tests. RESULTS: We enrolled 2,212 patients, 1,081 (49%) before protocol and 1,131 (51%) after protocol. Mean age (59 years vs. 60 years), female sex (49% vs. 49%), other demographics, comorbid illness, and PE risk stratification were similar before and after. After protocol, more VTE (35% from 26%, p < 0.001), PE (18% from 12%, p = 0.002), low-risk PE (28% from 18%, p < 0.001), and DVT (60% from 49%, p = 0.002) patients were treated as outpatients. Mortality, bleeding, and returns to ED were rare and did not increase after protocol. CONCLUSIONS: A treatment protocol combining risk-stratification, rivaroxaban treatment and defined follow-up is associated with an increase in PE and DVT patients treated as outpatients, with no increase in adverse outcomes.

Dietary Sodium Restriction Increases the Risk of Misinterpreting Mild Cases of Primary Aldosteronism.

CONTEXT: The aldosterone to renin ratio (ARR) is recommended to screen for primary aldosteronism (PA). OBJECTIVE: To evaluate whether dietary sodium restriction results in misinterpretation of PA screening. PARTICIPANTS: Untreated hypertensives with ARR more than 20 on a high dietary sodium intake (HS) were also evaluated on a low dietary sodium intake (LS) (n = 241). Positive screening for PA was defined as: plasma renin activity (PRA) less than or equal to 1.0 ng/mL · h with serum aldosterone more than or equal to 6 ng/dL. PA was confirmed by a 24-hour urinary aldosterone excretion more than or equal to 12 mcg with urinary sodium more than 200 mmol. RESULTS: Only 33% (79/241) of participants with an ARR more than 20 had a positive PA screen on HS. On LS, 56% (44/79) of these participants no longer met criteria for positive PA screening. When compared with participants with positive PA screening on both diets, participants with a positive screen on HS but negative on LS exhibited a significantly higher PRA on both diets. Remarkably, of the 48/79 participants who had PA confirmed, 52% had negative PA screening on LS. The distinguishing feature of these participants with "discordant" screening results was a larger rise in PRA on LS resulting in normalization of the ARR and higher Caucasian race prevalence. CONCLUSIONS: Sodium restriction is recommended in hypertension; however, it can significantly raise PRA, normalize the ARR, and result in false interpretation of PA screening. Milder phenotypes of PA, where PRA is not as suppressed, are most susceptible to dietary sodium influences on renin and ARR. Optimal screening for PA should occur under conditions of HS.