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PE Workup in 5 Steps

Written by Clay Smith

PE Workup in 5 Steps

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References

This figure is a composite of the great ideas of others, with some adaptation on my part.  The following is a list of the resources that went into making this figure.  I’m standing on their shoulders.

  1. Kline JA, Courtney DM, Kabrhel C, Moore CL, Smithline HA, Plewa MC, et al. Prospective multicenter evaluation of the pulmonary embolism rule-out criteria. J Thromb Haem. 2008;6:772–80.

  2. Geibel A, Zehender M, Kasper W, Olschewski M, Klima C, Konstantinides SV, et al. Prognostic value of the ECG on admission in patients with acute major pulmonary embolism. Eur Respir J. 2005;25: 843–8.

  3. Douma RA, Mos ICM, Erkins PMG, Nizet TAC, Durian MF, Hovens MM, et al. Performance of 4 Clinical Decision Rules in the Diagnostic Management of Acute Pulmonary Embolism – A Prospective Cohort Study. Ann Intern Med. 2011;154:709-18.

  4. Penaloza A, Verschuren F, Meyer G, Quentin-Georget S, Soulie C, Thys F, et al. Comparison of the Unstructured Clinician Gestalt, the Wells Score, and the Revised Geneva Score to Estimate Pretest Probability for Suspected Pulmonary Embolism. Ann Emerg Med. 2013;62:117-24.

  5. Righini M, Le Gal G, Aujesky D, Roy PM, Sanchez O, Verschuren F, et al. Diagnosis of pulmonary embolism by multidetector CT alone or combined with venous ultrasonography of the leg: a randomised non-inferiority trial. Lancet. 2008; 371:1343–52.

  6. Huisman MV for the Christopher Study Investigators. Effectiveness of Managing Suspected Pulmonary Embolism Using an Algorithm Combining Clinical Probability, D-Dimer Testing, and Computed Tomography. JAMA. 2006;295:172-9.

  7. Donze J, Le Gal G, Fine MJ, Roy PM, Sanchez O, Verschuren F, et al. Prospective validation of the pulmonary embolism severity index – a clinical prognostic model for pulmonary embolism. Thromb Haemost. 2008; 100:943–8.

  8. Chan CM, Woods C, Shorr AF. The validation and reproducibility of the pulmonary embolism severity index. J Thromb Haemost. 2010; 8:1509–14.

  9. Jimenez D, Aujesky D, Moores L, Gomez V, Lobo JL, Uresandi F, et al. Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism. Arch Intern Med. 2010; 170:1383–89.

  10. Righini M, Roy PM, Meyer G, Verschuren F, Aujesky D, Le Gal G. The simplified pulmonary embolism severity index (PESI): validation of a clinical prognostic model for pulmonary embolism. J Thromb Haemost. 2011; 9:2115–17.

  11. Becattini C, Vedovati MC, Agnelli G. Prognostic value of troponins in acute pulmonary embolism – a meta-analysis. Circulation. 2007; 116:427–33.

  12. Jimenez D, Uresandi F, Otero R, Lobo JL, Monreal M, Marti D, Zamora J, et al. Troponin-based risk stratification of patients with acute nonmassive pulmonary embolism – systematic review and metaanalysis. Chest. 2009;136:974–82.

  13. Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ, et al on behalf of the American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, Council on Peripheral Vascular Disease, and Council on Arteriosclerosis, Thrombosis and Vascular Biology. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation. 2011;123:1788 –1830.

  14. Konstantinides S, Goldhaber SZ. Pulmonary embolism: risk assessment and management. Eur Heart J. 2012 Dec;33(24):3014-22. doi: 10.1093/eurheartj/ehs258. Epub 2012 Sep 7.

  15. Dresden S, Mitchell P, Rahimi L, Leo M, Rubin-Smith J, Bibi S, et al. Right Ventricular Dilatation on Bedside Echocardiography Performed by Emergency Physicians Aids in the Diagnosis of Pulmonary Embolism. Ann Emerg Med. 2014;63:16-24.

  16. Grifoni S, Olivotto I, Cecchini P, Pieralli F, Camaiti A, Santoro G, et al. Short-term clinical outcome of patients with acute pulmonary embolism, normal blood pressure, and echocardiographic right ventricular dysfunction. Circulation. 2000;101:2817–22.

  17. Otero R, Trujillo-Santos J, Cayuela A, Rodriguez C, Barron M, Martin JJ, et al for the Registro Informatizado de la Enfermedad Tromboembólica (RIETE) Investigators. Haemodynamically unstable pulmonary embolism in the RIETE Registry: systolic blood pressure or shock index? Eur Respir J. 2007;30(6):1111-6.

  18. Thabut G, Thabut D, Myers RP, Bernard-Chabert B, Marrash-Chahla R, Mal H, et al. Thrombolytic therapy of pulmonary embolism: a meta-analysis. J Am Coll Cardiol. 2002;40:1660–67.

  19. Aujesky D, Roy PM, Verschuren F, Righini M, Osterwalder J, Egloff M, et al. Outpatient versus inpatient treatment for patients with acute pulmonary embolism: an international, open-label, randomised, non-inferiority trial. Lancet. 2011;378(9785):41-8.

  20. Agnelli G, Buller HR, Cohen A, Curto M, Gallus AS, Johnson M, et al. Oral Apixaban for the Treatment of Acute Venous Thromboembolism. N Engl J Med. 2013;369:799-808.

  21. Schulman S, Kearon C, Kakkar AK, Mismetti P, Schellong S, Eriksson H, et al for the RE-COVER Study Group. Dabigatran versus warfarin in the treatment of acute venous thromboembolism. N Engl J Med. 2009;361:2342–52.

  22. Büller HR, Prins MH, Lensin AW, Decousus H, Jacobson BF, Minar E, et al for the EINSTEIN–PE Investigators. Oral rivaroxaban for the treatment of symptomatic pulmonary embolism. N Engl J Med. 2012;366(14):1287-97.

  23. Sharifi M, Bay C, Skrocki L, Rahimi F, Mehdepour M. Moderate pulmonary embolism treated with thrombolysis (from the “MOPETT” Trial). Am J Cardiol. 2013;111(2):273-7.

  24. Huisman et al. How I diagnose acute pulmonary embolism. Blood. 2013;121(22):4443-4448.

  25. Penaloza et al. Risk stratification and treatment strategy of PE. Curr Opin Crit Care 2012, 18:318–325.

  26. Konstantinides SV, Vicaut E, Danays T, Becattini C, Bertoletti L, Beyer-Westendorf J, et al. Impact of Thrombolytic Therapy on the Long-Term Outcome of Intermediate-Risk Pulmonary Embolism. J Am Coll Cardiol. 2017 Mar 28;69(12):1536-1544. doi: 10.1016/j.jacc.2016.12.039.

  27. Freund Y, Cachanado M, Aubry A, Orsini C, Raynal PA, Féral-Pierssens AL, et al, PROPER Investigator Group. Effect of the Pulmonary Embolism Rule-Out Criteria on Subsequent Thromboembolic Events Among Low-Risk Emergency Department Patients: The PROPER Randomized Clinical Trial. JAMA. 2018 Feb 13;319(6):559-566. doi: 10.1001/jama.2017.21904.

  28. Belzile D, Jacquet S, Bertoletti L, Lacasse Y, Lambert C, Lega JC, Provencher S. Outcomes following a negative computed tomography pulmonary angiography according to pulmonary embolism prevalence: a meta-analysis of the management outcome studies. J Thromb Haemost. 2018 Jun;16(6):1107-1120. doi: 10.1111/jth.14021. Epub 2018 May 17.

  29. Righini M, Robert-Ebadi H, Le Gal G. Diagnosis of acute pulmonary embolism. J Thromb Haemost. 2017 Jul;15(7):1251-1261. doi: 10.1111/jth.13694.

  30. Wolf SJ, Hahn SA, Nentwich LM, Raja AS, Silvers SM, Brown MD. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Suspected Acute Venous Thromboembolic Disease. Ann Emerg Med. 2018 May;71(5):e59-e109. doi: 10.1016/j.annemergmed.2018.03.006.

8 Comments

    1. To clarify, some recommend unfractionated heparin (UFH) in "intermediate" risk PE, aka submassive PE, because they have risk of becoming unstable and may need tPA. These are patients with RV dysfunction. In my diagram I have two categories of "intermediate" risk: those with non-low PESI + no RV dysfunction and those with RV dysfunction. If no RVD, there is no need for UFH. But those with RVD have about a 5% chance of clinical decompensation (per PEITHO). So one could argue that PE patients with RVD who are not hemodynamically unstable should be started on UFH so it could be turned off if they developed hemodynamic instability and tPA was started. Truly unstable PE, defined as SBP </= 90 or drop in SBP by 40 from baseline for 15 minutes, should get tPA.

    1. This would be either Well’s score or revised Geneva score. You dichotomize either by grouping low/intermediate pretest probability as Decision Rule Unlikely; high pretest probability = Decision Rule Likely. Or you could use a simplified Well’s that dichotomizes PE Likely or PE Unlikely. That is my personal favorite.

    1. There is debate about this. In the PERC study, it was true physician gestalt. They were not instructed to use a structured decision instrument to determine whether or not to consider them low. So in keeping with the PERC study, I put it first. Only if not "gestalt low" or "PERC+" do I then quantify my gestalt – and that is to determine whether I should do a D-dimer or go straight to CTPA. This is also the order presented in a recent review by the PE gurus: J Thromb Haemost. 2017 Jul;15(7):1251-1261. doi: 10.1111/jth.13694.
      Diagnosis of acute pulmonary embolism.
      Here is my caveat. All these people get an ECG in my ED. I hold on my clinical gestalt judgment on whether or not to use PERC until after I look at the ECG. Here I am in the realm of opinion, so take that with a grain of salt. It would not be wrong to use a decision rule like Well’s or Geneva prior to PERC. I just like how PERC takes into consideration true gestalt. If I say to myself, "I don’t think they really have a PE," then I will use PERC. If I say, "Hmmm…I’m not sure…they might," then I don’t. In the original PERC study, "low gestalt" was defined as thinking they had <15% chance of PE.

  4. In the quantify gestalt step – what Well Score cut off are you using to define "Decision Rule Unlikely" and then proceeding to a D-Dimer. Seem like there should be a third arm. If the Decision rule is unlikely (for ex Wells Score = 0) – then no further workup required but if Decision Rule is given you an moderate risk then there is a third arm.

    Bottom line – what Wells Score gray zone – do you get a D-Dimer

    1. You can use Well’s or revised Geneva as three categories: low, intermediate, and high. But it’s much simpler to dichotomize the results by lumping together low/intermediate. Either way, it does not affect diagnostic performance. See https://www.ncbi.nlm.nih.gov/pubmed/21646554. Also for both scores, there is a simplified version that dichotomizes results, which was also just as good as splitting into 3 pretest probability categories. So, you can choose to use either the simplified, dichotomized versions or the original versions and lump low/intermediate as "PE Unlikely" and high as "PE Likely". To answer your question very specifically, anyone with a low to intermediate pretest probability on Well’s or revised Geneva gets a D-dimer (age adjusted). If negative, PE is excluded. If positive, CTPA. The one I use in practice is the simplified Well’s with Unlikely or Likely dichotomous result: ≤4 = Unlikely; >4 = Likely. Thankfully, we have MDCalc. https://www.mdcalc.com/wells-criteria-pulmonary-embolism

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