PE Prognostication with Dr Anand Senthi (part 2)

Ok, its here – the second part of the PE podcast.  This is where all the new concepts are squirrelled away.  We know that our current approach to PE is imperfect and likely does harm to a good number of patients – so can we do better?

Dr Anand Senthi is back to run us through a few new concepts – the test threshold, the mortality threshold and the role of the simplified PESI score in the prognostication process.

As usual there is a lot of evidence, key papers and scoring systems mentioned – so the links to these are below.

Enjoy, it is 33 minutes and I think might need a second listen if you are new to these ideas…

There was quite twitter debate a few weeks back when we started tweeting about some of these concepts – and it was hard to explain in 140 characters, so hopefully this podcast does the concepts more justice.  Would be keen to hear your opinions on the comments or Tweet me and @DrSenthi .

Here is a rough visual roadmap through Anand’s PE work up algorithm.  Looks complex, but it is really simple to do – faster than getting consent for a CTPA I reckon.  All the data you need is in your initial clinical assessment – just plug it into MDCalc and Bob’s your uncle!

Proposed PE algorithm
Proposed PE algorithm

 

DIRECT DOWNLOAD HERE

REFERENCES:

Dr Newman, David and Schriger “Rethinking Testing for Pulmonary Embolism: Less Is More” from Annals of EM 2011

Dr Kline’s paper from Journ. Thromb. and Haemostasis in2004 that calculated the “test threshold” for D-dimer at a pretest probability of 1.8%.

The Pauker and Kassirer method for calculating a test threshold – if you really want to know where they come up with these risk levels!

Mitchell (and Kline), Academic Emergency Medicine 2012  prospective study of the risk of contrast-induced nephropathy in patients undergoing CTPA.

HAS-BLED risk assessment tool for bleeding risk on anticoagulation (derived from AF patients – not VTE)

Outpatient Bleeding Risk Index,

1 point was scored for each of the following:

(1) 65 years or older,

(2) history of GI tract bleeding,

(3) history of stroke, and

(4) one or more comorbid conditions (recent myocardial infarction, anemia [hematocrit, <30%], renal impairment [creatinine level, >1.5 mg/dL {>133 µmol/L}], or diabetes mellitus).

The patient was low risk if the score was 0, moderate risk if the score was 1 or 2, and high risk if the score was 3 or more.

Possible PE Test thresholds – sensitivity analysis – a range of proposed test thresholds calculated using varying assumptions on risk and benefit sides of the equation.  This is from Anand’s ACEM talk

Calder, Herbert, Henderson – Annals of EM 2005  The mortality of untreated pulmonary embolism in emergency department patients – was likely less than 5%

Pines and Lessler (Acad Emerg Med, 2012)  performed the “mortality benefit threshold” calculations – i.e. how much benefit would treatment have to achieve in order to make a work-up worthwhile in a given pretest risk cohort? In the low risk group it works out at about 20%…. so you would need to have an intervention that dropped mortality by 20%….  this is not proven or even likely with current anticoagulation drugs!

The Simplified PESI (PE severity index) score on MDCalc – a tool to predict will do well after the diagnosis of PE.  If your sPESI is = 0, you are really very unlikely to die from a PE.  Jimenez et al showed the mortality risk was 1%, then subsequent prospective studies have shown even lower “treated mortality” rates

Moores, Jimenez et al (Journ Thromb & Haemost, 2010) showed the PESI score was better than troponin for predicting mortality in PE patients

 

 

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