Comparison of the revised Geneva score with the Wells rule for assessing clinical probability of pulmonary embolism.

BACKGROUND: The revised Geneva score, a standardized clinical decision rule in the diagnosis of pulmonary embolism (PE), was recently developed. The Wells clinical decision is widely used but lacks full standardization, as it includes subjective clinician's judgement. We have compared the performance of the revised Geneva score with the Wells rule, and their usefulness for ruling out PE in combination with D-dimer measurement. METHODS: In 300 consecutive patients, the clinical probability of PE was assessed prospectively by the Wells rule and retrospectively using the revised Geneva score. Patients comprised a random sample from a single center, participating in a large prospective multicenter diagnostic study. The predictive accuracy of both scores was compared by area under the curve (AUC) of receiver operating characteristic (ROC) curves. RESULTS: The overall prevalence of PE was 16%. The prevalence of PE in the low-probability, intermediate-probability and high-probability categories as classified by the revised Geneva score was similar to that of the original derivation set. The performance of the revised Geneva score as measured by the AUC in a ROC analysis did not differ statistically from the Wells rule. After 3 months of follow-up, no patient classified into the low or intermediate clinical probability category by the revised Geneva score and a normal D-dimer result was subsequently diagnosed with acute venous thromboembolism. CONCLUSIONS: This study suggests that the performance of the revised Geneva score is equivalent to that of the Wells rule. In addition, it seems safe to exclude PE in patients by the combination of a low or intermediate clinical probability by the revised Geneva score and a normal D-dimer level. Prospective clinical outcome studies are needed to confirm this latter finding.     

Ordering CT pulmonary angiography to exclude pulmonary embolism: defense versus evidence in the emergency room

Purpose

To identify reasons for ordering computed tomography pulmonary angiography (CTPA), to identify the frequency of reasons for CTPA reflecting defensive behavior and evidence-based behavior, and to identify the impact of defensive medicine and of training about diagnosing pulmonary embolism (PE) on positive results of CTPA.

Methods

Physicians in the emergency department of a tertiary care hospital completed a questionnaire before CTPA after being trained about diagnosing PE and completing questionnaires.

Results

Nine hundred patients received a CTPA during 3?years. For 328 CTPAs performed during the 1-year study period, 140 (43?%) questionnaires were completed. The most frequent reasons for ordering a CTPA were to confirm/rule out PE (93?%), elevated D-dimers (66?%), fear of missing PE (55?%), and Wells/simplified revised Geneva score (53?%). A positive answer for “fear of missing PE” was inversely associated with positive CTPA (OR 0.36, 95?% CI 0.14–0.92, p?=?0.033), and “Wells/simplified revised Geneva score” was associated with positive CTPA (OR 3.28, 95?% CI 1.24–8.68, p?=?0.017). The proportion of positive CTPA was higher if a questionnaire was completed, compared to the 2-year comparison period (26.4 vs. 14.5?%, OR 2.12, 95?% CI 1.36–3.29, p?p?=?0.067).

Conclusion

Reasons for CTPA reflecting defensive behavior—such as “fear of missing PE”—were frequent, and were associated with a decreased odds of positive CTPA. Defensive behavior might be modifiable by training in using guidelines.     

Clinical prediction rules for pulmonary embolism: a systematic review and meta‐analysis

Summary. Background: Pretest probability assessment is necessary to identify patients in whom pulmonary embolism (PE) can be safely ruled out by a negative D‐dimer without further investigations. Objective:   Review and compare the performance of available clinical prediction rules (CPRs) for PE probability assessment. Patients/methods: We identified studies that evaluated a CPR in patients with suspected PE from Embase, Medline and the Cochrane database. We determined the 95% confidence intervals (CIs) of prevalence of PE in the various clinical probability categories of each CPR. Statistical heterogeneity was tested. Results: We identified 9 CPR and included 29 studies representing 31215 patients. Pooled prevalence of PE for three‐level scores (low, intermediate or high clinical probability) was: low, 6% (95% CI, 4–8), intermediate, 23% (95% CI, 18–28) and high, 49% (95% CI, 43–56) for the Wells score; low, 13% (95% CI, 8–19), intermediate, 35% (95% CI, 31–38) and high, 71% (95% CI, 50–89) for the Geneva score; low, 9% (95% CI, 8–11), intermediate, 26% (95% CI, 24–28) and high, 76% (95% CI, 69–82) for the revised Geneva score. Pooled prevalence for two‐level scores (PE likely or PE unlikely) was 8% (95% CI,6–11) and 34% (95% CI,29–40) for the Wells score, and 6% (95% CI, 3–9) and 23% (95% CI, 11–36) for the Charlotte rule. Conclusion: Available CPR for assessing clinical probability of PE show similar accuracy. Existing scores are, however, not equivalent and the choice among various prediction rules and classification schemes (three‐ versus two‐level) must be guided by local prevalence of PE, type of patients considered (outpatients or inpatients) and type of D‐dimer assay applied.     

Echocardiographic assessment of right ventricle free wall strain for prediction of right coronary artery proximal lesion in patients with inferior myocardial infarction

In this study, our objective was to evaluate right ventricular functions with speckle-tracking and conventional echocardiographic methods in patients with acute inferior myocardial infarction and to investigate the correlation between the echocardiographic parameters and the prediction of the proximal RCA lesions. 77 patients were included in this study. Patients with a RCA occluded proximal to the right ventricular branch were assigned to Group 1 and patients with an RCA occlusion distal to the right ventricle branch were assigned to Group 2. All echocardiographic examinations were carried out within 24 h after PTCA, which was performed for the treatment of inferior myocardial infarction. RV TAPSE, RV TDI Sm, FAC, RV-FW strain, RV-FW SRE′, RV-FW SRA′ and RV E/Em which were statistically significant in univariate analysis were evaluated with the help of the multivariate logistic regression analysis. In the multivariate logistic regression test; RV-FW strain (OR 0.751, 95% CI 0.592–0.954, p?=?0.019) and RV E/Em (OR 0.442, 95% CI 0.252–0.776, p?=?0.004) were determined as the independent predictive parameters for proximal RCA occlusion. In the ROC analysis, RV-FW strain > ??14.75% predicted the proximal RCA occlusion with 83% sensitivity and 61% specificity (AUC?=?0.81, p?<?0.001) and RV E/Em?>?6.25 with 68% sensitivity and 80% specificity (AUC?=?0.79, p?<?0.001). In this study, we demonstrated that decreased RV FW strain and increased RV E/Em were predictive parameters for the presence of the proximal RCA in patients with acute inferior MI.     

Normal ventricular diameter ratio on CT provides adequate assessment for critical right ventricular strain among patients with acute pulmonary embolism

There is variability in guideline recommendations for assessment of the right ventricle (RV) with imaging as prognostic information after acute pulmonary embolism (PE). The objective of this study is to identify a clinical scenario for which normal CT-derived right-to-left ventricular (RV/LV) ratio is sufficient to exclude RV strain or PE-related short-term death. This retrospective cohort study included 579 consecutive subjects (08/2003-03/2010) diagnosed with acute PE with normal CT-RV/LV ratio (<0.9), 236 of whom received subsequent echocardiography. To identify a clinical scenario for which CT-RV/LV ratio was considered sufficient to exclude RV strain or PE-related short-term death, a multivariable logistic model was created to detect factors related to subjects for whom subsequent echocardiography detected RV strain or those who did not receive echocardiography and died of PE within 14 days (n?=?55). The final model included five variables (c-statistic?=?0.758, over-fitting bias?=?2.52?%): congestive heart failure (adjusted odds ratio, OR 4.32, 95?% confidence interval, CI 1.88–9.92), RV diameter on CT >45 mm (OR 3.07, 95?% CI 1.56–6.03), age >60 years (OR 2.59, 95?% CI 1.41–4.77), central embolus (OR 1.96, 95?% CI 1.01–3.79), and stage-IV cancer (OR 1.94, 95?% CI 0.99–3.78). If these five factors were all absent (37.1?% of the population), the probability that “CT-RV/LV ratio is sufficient to exclude RV strain/PE-related short-term death” was 0.97 (95?% CI?=?0.95–0.99). Normal CT-RV/LV ratio plus readily obtained five clinical predictors were adequate to exclude RV strain or PE-related short-term mortality.     

Predictors of acute scaffold recoil after implantation of the everolimus-eluting bioresorbable scaffold: an optical coherence tomography assessment in native coronary arteries

This study investigated the predictors of acute recoil after implantation of everolimus-eluting BRS based on optical coherence tomography (OCT). Thirty-nine patients (56 scaffolds) were enrolled. Acute absolute recoil by quantitative coronary angiography was defined as the difference between the mean diameter of the last inflated balloon (X) and the mean lumen diameter of BRS immediately after balloon deflation (Y). Acute percent recoil was defined as (X???Y)?×?100/X. Plaque eccentricity (PE) and plaque composition (PC) were assessed by OCT. PC was classified into two different types: calcific (score?=?1), fibrous and lipid (score?=?0). Based on the mean acute scaffold recoil value of the present study, scaffolds were divided into two groups: the low acute recoil group (LAR, n?=?34) and the high acute recoil group (HAR, n?=?22). Acute percent and absolute recoil were 6.4?±?3.0?% and 0.19?±?0.11 mm. PE, PC score and scaffold/artery ratio were significantly higher in HAR than in LAR. In multivariate logistic regression analysis, PE?>?1.49, PC score (score 1) and scaffold/artery ratio >1.07 were significant positive predictors for the occurrence of acute scaffold recoil (OR 10.7, 95?% CI 2.2–51.4, p?<?0.01; OR 5.6, 95?% CI 1.9–22.0, p?=?0.04; OR 12.4, 95?% CI 2.6–65.4, p?<?0.01, respectively). Acute recoil of BRS is influenced by BRS sizing as well as OCT-derived plaque characteristics.     

The pulmonary embolism rule‐out criteria (PERC) rule does not safely exclude pulmonary embolism

Summary. Background: The Pulmonary Embolism Rule‐out Criteria (PERC) rule is a clinical diagnostic rule designed to exclude pulmonary embolism (PE) without further testing. We sought to externally validate the diagnostic performance of the PERC rule alone and combined with clinical probability assessment based on the revised Geneva score. Methods: The PERC rule was applied retrospectively to consecutive patients who presented with a clinical suspicion of PE to six emergency departments, and who were enrolled in a randomized trial of PE diagnosis. Patients who met all eight PERC criteria [PERC_(?)] were considered to be at a very low risk for PE. We calculated the prevalence of PE among PERC_(?) patients according to their clinical pretest probability of PE. We estimated the negative likelihood ratio of the PERC rule to predict PE. Results: Among 1675 patients, the prevalence of PE was 21.3%. Overall, 13.2% of patients were PERC_(?). The prevalence of PE was 5.4% [95% confidence interval (CI): 3.1–9.3%] among PERC_(?) patients overall and 6.4% (95% CI: 3.7–10.8%) among those PERC_(?) patients with a low clinical pretest probability of PE. The PERC rule had a negative likelihood ratio of 0.70 (95% CI: 0.67–0.73) for predicting PE overall, and 0.63 (95% CI: 0.38–1.06) in low‐risk patients. Conclusions: Our results suggest that the PERC rule alone or even when combined with the revised Geneva score cannot safely identify very low risk patients in whom PE can be ruled out without additional testing, at least in populations with a relatively high prevalence of PE.     

Automated Pulmonary Embolism Risk Classification and Guideline Adherence for Computed Tomography Pulmonary Angiography Ordering

Background

The assessment of clinical guideline adherence for the evaluation of pulmonary embolism (PE) via computed tomography pulmonary angiography (CTPA) currently requires either labor‐intensive, retrospective chart review or prospective collection of PE risk scores at the time of CTPA order. The recording of clinical data in a structured manner in the electronic health record (EHR) may make it possible to automate the calculation of a patient's PE risk classification and determine whether the CTPA order was guideline concordant.

Objectives

The objective of this study was to measure the performance of automated, structured data–only versions of the Wells and revised Geneva risk scores in emergency department (ED) encounters during which a CTPA was ordered. The hypothesis was that such an automated method would classify a patient's PE risk with high accuracy compared to manual chart review.

Methods

We developed automated, structured data–only versions of the Wells and revised Geneva risk scores to classify 212 ED encounters during which a CTPA was performed as “PE likely” or “PE unlikely.” We then combined these classifications with D‐dimer ordering data to assess each encounter as guideline concordant or discordant. The accuracy of these automated classifications and assessments of guideline concordance were determined by comparing them to classifications and concordance based on the complete Wells and revised Geneva scores derived via abstractor manual chart review.

Results

The automatically derived Wells and revised Geneva risk classifications were 91.5 and 92% accurate compared to the manually determined classifications, respectively. There was no statistically significant difference between guideline adherence calculated by the automated scores compared to manual chart review (Wells, 70.8% vs. 75%, p = 0.33; revised Geneva, 65.6% vs. 66%, p = 0.92).

Conclusion

The Wells and revised Geneva score risk classifications can be approximated with high accuracy using automated extraction of structured EHR data elements in patients who received a CTPA. Combining these automated scores with D‐dimer ordering data allows for the automated assessment of clinical guideline adherence for CTPA ordering in the ED, without the burden of manual chart review.

     

The utility of global longitudinal strain in the identification of prior myocardial infarction in patients with preserved left ventricular ejection fraction

Prior myocardial infarction (MI) is associated with increased mortality and is prevalent in certain high risk patient groups. Electrocardiogram may be used in diagnosis, however, sensitivity is limited, thus non-invasive imaging techniques may improve diagnosis. We investigated whether global longitudinal strain (GLS) and longitudinal strain parameters are reduced in patients with prior MI but preserved left ventricular ejection fraction (LVEF). The study included 40 clinical patients with prior MI occurring >3 months previously (defined as subendocardial hyperenhancement on late Gadolinium enhancement imaging) with LVEF?≥?55% and 40 controls matched for age and LVEF. GLS, global longitudinal strain rate (GLSR) and early diastolic longitudinal strain rate (GLSRe) were measured from cine imaging feature tracking analysis. Presence of wall motion abnormality (WMA) and minimum systolic wall thickening (SWT) were calculated from cine imaging. GLS was ?17.3?±?3.7% in prior MI versus ?19.3?±?1.9% in controls (p?=?0.012). GLSR was ?88.0?±?33.7%/s in prior MI versus ?103.3?±?26.5%/s in controls (p?=?0.005). GLSRe was 76.4?±?28.4%/s in prior MI versus 95.5?±?26.0%/s in controls (p?=?0.001). GLS accurately identified prior MI [AUC 0.662 (95% CI 0.54–0.785) p?=?0.012] whereas WMA [AUC 0.500 (95% CI 0.386–0.614) p?=?1.0] and minimum SWT [AUC 0.609 (95% CI 0.483–0.735) p?=?0.093] did not. GLS, GLSR and GLSRe are reduced in prior MI with preserved LVEF. Normal LVEF and lack of WMA cannot exclude prior MI. Prior MI should be considered when reduced GLS, GLSR or GLSRe are detected by non-invasive imaging.     

Right ventricular function and mechanics in chemotherapy- and radiotherapy-naïve cancer patients

The present research evaluated right ventricular (RV) structure, function and mechanics in the cancer patients before initiation of chemo- or radiotherapy, and the association between cancer and decreased RV longitudinal strain. This retrospective investigation included 101 chemo- and radiotherapy-naïve patients with solid cancer and 38 age- and gender-matched controls with similar cardiovascular risk profile. Echocardiographic examination and strain evaluation was performed in all participants. RV structure and RV systolic and diastolic function estimated with conventional echocardiographic parameters were similar between the cancer patients and controls. However, RV global longitudinal strain (??22.7?±?2.6% vs. ??21.1?±?2.4%, p?<?0.001) was significantly decreased in the cancer patients than in controls. The same was revealed for RV free wall endocardial (??33.6?±?4.3% vs. ??31.4?±?4.0%, p?=?0.006) and mid-myocardial (??25.2?±?3.6% vs. ??23.7?±?3.8%, p?=?0.035) longitudinal RV strains, whereas difference was not found in RV free wall epicardial longitudinal strain. The presence of cancer was independently of age, gender, body mass index, left ventricular hypertrophy, diabetes, hypertension and pulmonary pressure associated with reduced RV global longitudinal strain (OR 3.79; 95% CI 2.18–10.92, p?<?0.001), as well as with decreased free wall RV longitudinal strain (OR 5.73; 95% CI 3.17–9.85, p?<?0.001). RV strain is deteriorated in the chemo- and radiotherapy-naïve cancer patients. Endocardial and mid-myocardial layers are more affected than epicardial strain in the cancer patients. The presence of cancer is independently of other clinical parameters associated with reduced RV longitudinal strain.     

Comorbidity burden conditions the prognostic performance of D-dimer in elderly patients with acute pulmonary embolism

Introduction

The prognostic accuracy of D-dimer for risk assessment in acute Pulmonary Embolism (APE) patients may be hampered by comorbidities. We investigated the impact of comorbidity burden (CB) by using the Charlson Comorbidity Index (CCI), on the prognostic ability of D-dimer to predict 30 and 90-day mortality in hemodynamically stable elderly patients with APE.

Quantification of pulmonary regurgitation and prediction of pulmonary valve replacement by echocardiography in patients with congenital heart defects in comparison to cardiac magnetic resonance imaging

Pulmonary regurgitation (PR) is common in patients with congenital heart defects (CHD) and contributes to morbidity and mortality in the long-term. We investigated in this retrospective analysis whether readily accessible echocardiographic parameters are useful for quantification of PR and for predicting pulmonary valve replacement (PVR) in comparison to the gold-standard phase contrast (PC) flow measurements from cardiovascular magnetic resonance (CMR). Continuous wave (CW) Doppler and colour flow images in echocardiograms from 53 patients with CHD were analysed. Slope and jet-to-RVOT ratio correlated significantly with CMR-assessed regurgitation fraction (RF), whereas pressure half time (PHT) showed an inverse correlation. Patients with mild PR in CMR had significantly higher PHT, lower slope and jet-to-RVOT ratio than patients with moderate or severe regurgitation. The AUC regarding PR severity was 0.778 for PHT (95% CI, 0.649–0.907; P?=?0.007 for CMR-RF?≤?35%), 0.744 for slope (95% CI, 0.603–0.885; P?=?0.017 for CMR-RF?>?35%) and 0.652 for jet-to-RVOT ratio (95% CI, 0.473–0.860; P?=?0.168 for CMR-RF?>?35%). The optimal cut-off values calculated from ROC analysis were 95 ms for PHT and 4.9 m/s² for slope. In logistic regression analysis, slope emerged as the most valuable parameter for predicting the indication for PVR (OR 12.9, 95% CI, 1.8–90.9, P?=?0.010). In conclusion, echocardiographic assessment of PR was feasible. Both parameters, PHT and in particular slope, were predictors for PVR. Thus, echocardiography appears appropriate in the management of patients with PR.     

Predictive role of interleukin-6 and CAT score in mechanical ventilation in patients with chronic obstructive pulmonary disease at the acute exacerbation stage in the emergency department

BACKGROUND:The study aimed to evaluate the predictive role of interleukin-6(IL-6)and chronic obstructive pulmonary disease(COPD)assessment test(CAT)score in mechanical ventilation(MV)in COPD patients at the acute exacerbation stage in the emergency department(ED).METHODS:For a one-year period,among adult patients in the ED who met the criteria of acute exacerbation of COPD,158 who received MV within 48 hours after admission were compared to 294 who didn't require MV within the same period after admission.IL-6 level and CAT score were compared between the two groups.The predicted value of IL-6 and CAT score was assessed by logistic regression analysis and a receiver operating characteristic(ROC)curve.RESULTS:The IL-6 and CAT scores in the 158 MV patients were much higher than those without.IL-6 and CAT scores were independent predictors of MV within 48 hours using logistic regression analysis(IL-6:odds ratio[OR]1.053,95%confidence interval[CI]1.039–1.067,P<0.001;CAT score:OR 1.122,95%CI 1.086–1.159,P<0.001).The combination of IL-6 and CAT scores(area under ROC curve[AUC]0.826,95%CI 0.786–0.866,P<0.001)improved the accuracy of predicting MV within 48 hours when compared with IL-6(AUC 0.752,95%CI 0.703–0.800,P<0.001)and CAT scores alone(AUC 0.739,95%CI 0.692–0.786,P<0.001).The sensitivity and specificity were 69.6%,74.1%,75.32%and 63.6%,respectively.CONCLUSION:The combined of IL-6 and CAT scores is useful for evaluating the risk of COPD patients at acute exacerbation in ED,and can provide a predictive value for MV or not within 48 hours.     

Clinical experience and pre-test probability scores in the diagnosis of pulmonary embolism

BACKGROUND: The Geneva and Wells pre-test probability scores are intended to replace empirical assessment of patients with suspected pulmonary embolism (PE). The effect of clinical experience on the inter-rater variability of these scores, and on empirical judgement, is unknown. AIM: To determine whether medical staff appointment grade affects the inter-rater variability of these pre-test probability scores, or empirical assessment, in patients with suspected PE. DESIGN: Questionnaire survey. METHODS: Doctors were grouped by grade (mean number of years since graduation+/-SEM): house officers 0.7+/-0.2, registrars 6.3+/-0.6, consultants 25+/-4 and applied pre-test probability scores to actual case scenarios. RESULTS: The Geneva score was the most consistent method of determining pre-test probability and was unaffected by clinical experience (Geneva kappa=0.73, Wells kappa=0.38, empirical kappa=0.23, p<0.001 ). With empirical judgement, inter-rater variability was inversely proportional to clinical experience (house officers kappa=0.37, registrars kappa=0.24, consultants kappa= 0.16, p<0.05). DISCUSSION: The Geneva score was the least variable method and can be applied by junior or senior doctors. Using empirical judgement, junior doctors were more likely to agree on the pre-test probability of PE than were their more senior colleagues. This may imply that as physicians gain experience, they recognize that the diagnosis of PE can be difficult to assess and are reluctant to exclude it on clinical grounds.     

Resting global myocardial work can improve interpretation of exercise stress echocardiography

Sensitivity and specificity of ESE to determine hemodynamically significant coronary artery disease (CAD) is limited by subjective qualitative interpretation resulting in false-positive results. The objective of this study was to determine whether resting myocardial work estimated from non-invasive left ventricular pressure-strain loops can help improve the interpretation of exercise stress echocardiography (ESE). Resting global myocardial work was performed on 288 patients referred for clinically indicated ESE with no resting regional wall motion abnormalities and normal ejection fraction (≥?55%). Coronary angiography was used to validate the presence of significant CAD in those with a positive ESE. Resting global myocardial work index (GWI) was significantly reduced (p?<?0.001) in patients with true-positive (1544?±?354 mmHg%) compared to negative (1819?±?317 mmHg%) and false-positive (1857?±?344 mmHg%) ESE. A GWI of?≤?1391 mmHg (AUC 0.73; sensitivity 94%; specificity 73%) predicted true-positive ESE. Predictors of a true-positive ESE were (1) lower myocardial work efficiency (odds ratio 0.731, 95% CI 0.58–0.92, p?=?0.007), (2) lower GWI (odds ratio 0.997, 95% CI 0.996–0.999, p?=?0.006) (3) male gender (odds ratio 5.47, 95% CI 1.84–16.31, p?=?0.002) and (4) E/e? ratio (odds ratio 1.15, CI 1.01–1.31, p?=?0.032). Myocardial work is a potentially valuable quantitative parameter that provides incremental value over qualitative ESE interpretation and improves appropriate patient selection for coronary angiography.

     

Determinants of image quality of rotational angiography for on-line assessment of frame geometry after transcatheter aortic valve implantation

To study the determinants of image quality of rotational angiography using dedicated research prototype software for motion compensation without rapid ventricular pacing after the implantation of four commercially available catheter-based valves. Prospective observational study including 179 consecutive patients who underwent transcatheter aortic valve implantation (TAVI) with either the Medtronic CoreValve (MCS), Edward-SAPIEN Valve (ESV), Boston Sadra Lotus (BSL) or Saint-Jude Portico Valve (SJP) in whom rotational angiography (R-angio) with motion compensation 3D image reconstruction was performed. Image quality was evaluated from grade 1 (excellent image quality) to grade 5 (strongly degraded). Distinction was made between good (grades 1, 2) and poor image quality (grades 3–5). Clinical (gender, body mass index, Agatston score, heart rate and rhythm, artifacts), procedural (valve type) and technical variables (isocentricity) were related with the image quality assessment. Image quality was good in 128 (72?%) and poor in 51 (28?%) patients. By univariable analysis only valve type (BSL) and the presence of an artefact negatively affected image quality. By multivariate analysis (in which BMI was forced into the model) BSL valve (Odds 3.5, 95?% CI [1.3–9.6], p?=?0.02), presence of an artifact (Odds 2.5, 95?% CI [1.2–5.4], p?=?0.02) and BMI (Odds 1.1, 95?% CI [1.0–1.2], p?=?0.04) were independent predictors of poor image quality. Rotational angiography with motion compensation 3D image reconstruction using a dedicated research prototype software offers good image quality for the evaluation of frame geometry after TAVI in the majority of patients. Valve type, presence of artifacts and higher BMI negatively affect image quality.     

B-type natriuretic peptide as an indicator of right ventricular dysfunction in acute pulmonary embolism

Objective: B‐type natriuretic peptide (BNP) is a neurohormone secreted from cardiac ventricles in response to ventricular strain. The aim of present study was to evaluate the role of BNP in the diagnosis of the right ventricular (RV) dysfunction in acute pulmonary embolism (PE). Methods: BNP levels were measured in patients with acute PE as diagnosed by high probability lung scan or positive spiral computed tomography. All patients underwent standard echocardiography and blood tests during the second hour of the diagnosis. Results: Forty patients diagnosed as acute PE (mean age, 60.4 ± 13.2 years; 62.5% women) were enrolled in this study. Patients with RV dysfunction had significantly higher BNP levels than patients without RV dysfunction (426 ± 299.42 pg/ml vs. 39.09 ± 25.22 pg/ml, p < 0.001). BNP‐discriminated patients with or without RV dysfunction (area under the receiver operating characteristic curve, 0.943; 95% CI, 0.863–1.022). BNP > 90 pg/ml was associated with a risk ratio of 165 (95% CI, 13.7–1987.2) for the diagnosis of RV dysfunction. There was a significant correlation between RV end‐diastolic diameter and BNP (r = 0.89, p < 0.001). Sixteen patients (40%) were diagnosed as having low‐risk PE, 19 patients (47.5%) with submassive PE and five patients (12.5%) with massive PE. The mean BNP was 39.09 ± 25.2, 378.4 ± 288.4 and 609.2 ± 279.2 pg/ml in each group respectively. Conclusion: Measurement of BNP levels may be a useful approach in diagnosis of RV dysfunction in patients with acute PE. The possibility of RV dysfunction in patients with plasma BNP levels > 90 pg/ml should be strongly considered.     

Prospective comparison of clinical prognostic scores in elder patients with a pulmonary embolism

Summary. Background: The Geneva Prognostic Score (GPS), the Pulmonary Embolism Severity Index (PESI) and its simplified version (sPESI) are well‐known clinical prognostic scores for a pulmonary embolism (PE). Objectives: To compare the prognostic performance of these scores in elderly patients with a PE. Patients and methods: In a multicenter Swiss cohort of elderly patients with venous thromboembolism, we prospectively studied 449 patients aged ≥ 65 years with a symptomatic PE. The outcome was 30‐day overall mortality. We dichotomized patients as low vs. higher risk in all three scores using the following thresholds: GPS scores ≤ 2 vs. > 2, PESI risk classes I–II vs. III–V and sPESI scores 0 vs. ≥ 1. We compared 30‐day mortality in low‐ vs. higher‐risk patients and the areas under the receiver‐operating characteristic curve (ROC). Results: Overall, 3.8% of patients (17/449) died within 30 days. The GPS classified a greater proportion of patients as low risk (92% [413/449]) than the PESI (36.3% [163/449]) and the sPESI (39.6% [178/449]) (P < 0.001 for each comparison). Low‐risk patients based on the sPESI had a mortality of 0% (95% confidence interval [CI] 0–2.1%) compared with 0.6% (95% CI 0–3.4%) for low‐risk patients based on the PESI and 3.4% (95% CI 1.9–5.6%) for low‐risk patients based on the GPS. The areas under the ROC curves were 0.77 (95% CI 0.72–0.81), 0.76 (95% CI 0.72–0.80) and 0.71 (95% CI 0.66–0.75), respectively (P = 0.47). Conclusions: In this cohort of elderly patients with PE, the GPS identified a higher proportion of patients as low risk but the PESI and sPESI were more accurate in predicting mortality.     

Right ventricular relative wall thickness as a predictor of outcomes and of right ventricular reverse remodeling for patients with pulmonary hypertension

Mid-term right ventricular (RV) reverse remodeling after treatment in patients with pulmonary hypertension (PH) is associated with long-term outcome as well as baseline RV remodeling. However, baseline factors influencing mid-term RV reverse remodeling after treatment and its prognostic capability remain unclear. We studied 54 PH patients. Mid-term RV remodeling was assessed in terms of the RV area, which was traced planimetrically at the end-systole (RVESA). RV reverse remodeling was defined as a relative decrease in the RVESA of at least 15% at 10.2?±?9.4 months after treatment. Long-term follow-up was 5 years. Adverse events occurred in ten patients (19%) and mid-term RV reverse remodeling after treatment was observed in 37 (69%). Patients with mid-term RV reverse remodeling had more favorable long-term outcomes than those without (log-rank: p?=?0.01). Multivariate logistic regression analysis showed that RV relative wall thickness (RV-RWT), as calculated as RV free-wall thickness/RV basal linear dimension at end-diastole, was an independent predictor of mid-term RV reverse remodeling (OR 1.334; 95% CI, 1.039–1.713; p?=?0.03). Moreover, patients with RV-RWT ≥0.21 showed better long-term outcomes than did those without (log-rank p?=?0.03), while those with RV-RWT ≥0.21 and mid-term RV reverse remodeling had the best long-term outcomes. Patients with RV-RWT <0.21 and without mid-term RV reverse remodeling, on the other hand, had worse long-term outcomes than other sub-groups. In conclusions, RV-RWT could predict mid-term RV reverse remodeling after treatment in PH patients, and was associated with long-term outcomes. Our finding may have clinical implications for better management of PH patients.     

Accuracy of Very Low Pretest Probability Estimates for Pulmonary Embolism Using the Method of Attribute Matching Compared with the Wells Score

Objectives: Attribute matching matches an explicit clinical profile of a patient to a reference database to estimate the numeric value for the pretest probability of an acute disease. The authors tested the accuracy of this method for forecasting a very low probability of venous thromboembolism (VTE) in symptomatic emergency department (ED) patients. Methods: The authors performed a secondary analysis of five data sets from 15 hospitals in three countries. All patients had data collected at the time of clinical evaluation for suspected pulmonary embolism (PE). The criterion standard to exclude VTE required no evidence of PE or deep venous thrombosis (DVT) within 45 days of enrollment. To estimate pretest probabilities, a computer program selected, from a large reference database of patients previously evaluated for PE, patients who matched 10 predictor variables recorded for each current test patient. The authors compared the outcome frequency of having VTE [VTE(+)] in patients with a pretest probability estimate of <2.5% by attribute matching, compared with a value of 0 from the Wells score. Results: The five data sets included 10,734 patients, and 747 (7.0%, 95% confidence interval [CI] = 6.5% to 7.5%) were VTE(+) within 45 days. The pretest probability estimate for PE was <2.5% in 2,975 of 10,734 (27.7%) patients, and within this subset, the observed frequency of VTE(+) was 48 of 2,975 (1.6%, 95% CI = 1.2% to 2.1%). The lowest possible Wells score (0) was observed in 3,412 (31.7%) patients, and within this subset, the observed frequency of VTE(+) was 79 of 3,412 (2.3%, 95% CI = 1.8% to 2.9%) patients. Conclusions: Attribute matching categorizes over one‐quarter of patients tested for PE as having a pretest probability of <2.5%, and the observed rate of VTE within 45 days in this subset was <2.5%. ACADEMIC EMERGENCY MEDICINE 2010; 17:133–141 © 2010 by the Society for Academic Emergency Medicine