Diagnostic de l’embolie pulmonaire

The diagnosis of pulmonary embolism (PE) is nowadays based on the sequential use of several diagnostic tests rather than on a single test. These diagnostic strategies are safe and have been prospectively validated. The first step after identifying patients with suspicion of PE is to establish the pre-test clinical probability. Several scores are available in order to make a standardised and reproducible assessment of the clinical probability, and therefore represent precious diagnostic tools. Indeed, clinical probability guides further investigations. Indeed, in patients with a low or an intermediate clinical probability or an “unlikely” probability, PE can be safely ruled out by negative D-dimers in approximately one third of outpatients without additional imaging. In case of positive D-dimers and a high clinical probability or a “likely” clinical probability, CT pulmonary angiography is now the recommended imaging technique. However, lower limb venous compression ultrasound and ventilation/perfusion scans remain useful in patients with contra-indications to CT, mainly those with renal insufficiency. Finally, some novel diagnostic tests seem promising. For example, V/Q SPECT has arisen as a highly accurate test and a potential alternative to CTPA. However, prospective management outcome studies are still lacking and are warranted before its implementation in routine clinical practice.     

Apport de l’imagerie endocoronaire dans le syndrome coronarien aigu

Acute coronary syndrome (ACS) remains a major cause of mortality and morbidity in the world, although it has considerably decreased through technical and pharmacological advances. The physiopathological approach of the ACS has progressed considerably in recent years thanks to the anatomopathological work and the data of the endocoronary imaging, in particular of the endovascular ultrasound (IVUS). Plaque rupture is the most common cause of ACS, however OCT (optical coherence tomography) studies have shown that surface plaque erosion was more common than thought. The use of OCT in the ACS may prove to be a valuable diagnostic aid: study of the culpable lesion, spontaneous coronary dissection or intramural spontaneous hematoma, stent thrombosis; from a therapeutic point of view: reduction of the risk of stent malapposition, additional technique, delayed stenting, implantation of a bioresorbable stent, medical treatment of ACS without stenting. Endocoronary imaging, especially OCT, will of course never be systematic as treatment of ACS, but providing excellent value for both diagnosis and treatment, it must be an integral part of the therapeutic arsenal available in cathlab.     

Prise en charge ambulatoire de l’embolie pulmonaire diagnostiquée aux urgences

In the emergency department, the management of patients with pulmonary embolism depends on the early mortality risk. Outpatient care is possible in low-risk patients. We present the existing scores and the strategy proposed by the North Alps Emergency Network, which uses the simplified PESI score (Pulmonary Embolism Severity Index) to select those low-risk patients, candidates for early discharge.