D-dimer for risk stratification in patients with acute pulmonary embolism.

BACKGROUND: Risk stratification is currently recommended for the initial management of patients with acute pulmonary embolism (PE). METHODS: We performed a meta-analysis of studies in patients with acute PE to assess the prognostic value of elevated D-dimer levels for short-term (within 30 days) and 3-month mortality. The association between D-dimer levels and markers of PE severity was also reviewed. Unrestricted searches were performed using the terms D-dimer and pulmonary embolism. Studies reporting on D-dimer levels and mortality and/or markers of PE severity were included in the review. A random-effects model was used to pool study results, funnel-plot inspection to evaluate publication bias and I squared testing to test for heterogeneity. RESULTS: Five studies (2,885 patients) reported on D-dimer levels and short-term mortality. D-dimer levels above a prognostic cut-off were significantly associated with short-term mortality in the overall population (OR: 2.76; 95% CI: 1.83-4.14; I(2) = 0%) and in hemodynamically stable patients (three studies, 874 patients; OR: 4.28; 95% CI: 1.88-9.71; I(2) = 0%). Four studies (1,254 patients) reported on D-dimer levels and 3-month mortality. D-dimer levels above a prognostic cut-off were associated with 3-month mortality (OR: 4.29; 95% IC: 1.70-10.79; I(2) = 0%). Overall, 14 studies assessed the association between D-dimer and markers of PE severity. An association has been observed between D-dimer levels and the degree of pulmonary artery obstruction. CONCLUSION: In patients with acute PE elevated D-dimer is associated with increased short-term and 3-month mortality, suggesting the potential of using this test for both diagnosis and risk stratification.

The Utility of Paraspinal Acoustic Windows for the Evaluation of Acute Dissection of Descending Thoracic Aorta in the Emergency Setting.

Acute aortic dissection (AAD) is the prevalent acute aortic syndrome characterized by rapid onset and progression with time-dependent prognosis. When suspecting AAD of descending thoracic aorta in the context of the emergency department setting, computed tomography scanning and trans-esophageal echocardiography are the most useful imaging modalities. The sensitivity of transthoracic echocardiography in diagnosing for type B dissection is only 31%-55% when compared with other modalities. We describe the case of a 62-year-old female with a clinical history of Marfan syndrome where the low sensitivity of the transthorac approach in the detection of descending aortic dissection was overcomed by the posterior thoracic approach with the posterior paraspinal window (PPW). In the literature, are described just few reports where echocardiography via the PPW makes it possible to diagnose acute descending aortic syndrome.