Does Negative CTPA Rule Out High Pretest Probability PE?

Does Negative CTPA Rule Out High Pretest Probability PE?

For patients with high pretest probability for pulmonary embolism, a negative CT pulmonary angiography alone does not appear to adequately rule out venous thromboembolism.

Syncope/Pre-syncope and Outcome in PE Patients

Syncope/Pre-syncope and Outcome in PE Patients

Syncope or pre-syncope in patients with PE was associated with an increased risk for 30-day mortality (43% vs 6%) and was an independent predictor of 30-day mortality when accompanied by hemodynamic instability on admission.  Don't try to treat them as an outpatient.

Should We Anticoagulate Subsegmental PE?

Should We Anticoagulate Subsegmental PE?

This systematic review suggested that we don't know if treating subsegmental PE harms or helps.  But this may inform decision making in patients in whom it would be very dangerous to anticoagulate.  It suggests a state of equipoise.

Prevalence of PE in Syncope

Prevalence of PE in Syncope

This large, retrospective study found the prevalence of PE in hospitalized patients discharged with a diagnosis of syncope was 0.15% to 2.1%; 0.35% to 2.63% at 90-day follow up.  This was much lower than the PESIT trial, at 17.3%.

Treatment of Massive PE in Pregnancy

Treatment of Massive PE in Pregnancy

Treatment with lytics for acute PE (mostly massive or with arrest) in pregnancy out to 6 weeks postpartum was associated with 94% overall maternal survival and 88% fetal survival.  Major bleeding occurred in 17% of pregnant women and 58% of those in the postpartum period.

Wells Score Plus D-dimer for PE Rule-out

Wells Score Plus D-dimer for PE Rule-out

Patients in an ED setting with a low pretest probability based on the Wells score, and a negative D-dimer were safely ruled out for pulmonary embolism without further diagnostic imaging.

Low-Dose Perfusion or CTPA for PE in Pregnancy?

Low-Dose Perfusion or CTPA for PE in Pregnancy?

Low dose perfusion-only (LDQ) nuclear scan (the "Q" of the V/Q scan) or CTPA are the imaging studies of choice to diagnose PE in pregnant women.  LDQ (using one-third the normal technetium) had high accuracy and lower radiation dose and may be preferred over CTPA, assuming the CXR is normal.

Diagnose PE Like a Pro

Diagnose PE Like a Pro

If clinical gestalt for PE is low, use PERC to rule out PE.  If not ruled out, use a validated tool to determine pretest probability of PE: WellsRevised Geneva, or simplified versions of either score.  If non-high or "unlikely" pretest probability, order D-dimer, adjusting for age (<500 or <age x 10).  If D-dimer is negative, PE is ruled out.  If positive, order CT pulmonary angiogram.

Alteplase for Submassive PE

Alteplase for Submassive PE

This early study of thrombolytics plus heparin for submassive PE showed no mortality benefit but did show a decrease in need for escalation of care compared with heparin alone.  Subsequent studies call lytics for submassive PE into question, so take the current evidence into account.

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