Pulmonary embolism: role of ventilation-perfusion scintigraphy.

Semin Nucl Med. 2013 Mar;43(2):82-7

Authors: Onyedika C, Glaser JE, Freeman LM

Abstract
The evaluation for pulmonary embolism in the emergency setting has many challenges. Patients often present with symptoms that are nonspecific. Emergency Department physicians utilize their own subjective judgment or objective clinical algorithms, such as the Wells Score to assess the likelihood of the patient having PE. Other techniques, such as D-dimer assays and Doppler ultrasound leg studies for deep venous thrombosis are very useful, as well. Ventilation-perfusion lung scans and computed tomography pulmonary angiography are both available in most institutions. However, factors such as sensitivity or specificity, overnight availability, radiation exposure, and comfort with interpretation criteria play a role in deciding which procedure should be used. Relative merits of both the procedures will be discussed.

PMID: 23414824 [PubMed - in process]

Predicting short term mortality after investigation for venous thromboembolism.

Thromb Res. 2013 Feb 14;

Authors: Hogg K, Hinchliffe E, Haslam S, Sethi B, Carrier M, Lecky F

Abstract
INTRODUCTION: Deaths following diagnosis of venous thromboembolism (VTE) often result from another concurrent illness. The specificity of mortality markers predicting death from pulmonary embolism is unknown. The aim of this analysis was to compare blood predictors of death in patients with confirmed VTE to patients with negative investigations for VTE. MATERIALS AND METHODS: Consecutive patients investigated for VTE were prospectively consented from a single hospital over 9months. VTE was diagnosed and excluded with a standard diagnostic algorithm. Blood was drawn for biomarker analysis and analyzed in batches for NT-proBNP, high sensitivity troponin T, C-reactive protein (CRP), fatty acid binding protein (FABP) and ischemia modified albumin (IMA). Participants were followed for 3months. The cohort was analyzed in two groups: those diagnosed with VTE and those who had thrombosis excluded. Regression analysis for 3-month mortality was performed for each group. RESULTS: 16/153 patients diagnosed with VTE died within three months (10.5%) as did 23/606 patients who had negative investigations for VTE (3.8%). Predictors for death following VTE included cancer, NT-proBNP, troponin T, FABP, and Hb<95g/L. NT-proBNP>500pg/ml in acute cancer associated VTE predicted death with C-statistic of 0.89 (0.80-0.99). Cancer, NT-proBNP and troponin T also predicted death in patients with negative investigations for VTE. CONCLUSION: Several blood markers are not specific for death from PE and may be surrogate markers of global declining health.

PMID: 23415412 [PubMed - as supplied by publisher]

Outpatient diagnosis of acute chest pain in adults.

Am Fam Physician. 2013 Feb 1;87(3):177-82

Authors: McConaghy JR, Oza RS

Abstract
Approximately 1 percent of primary care office visits are for chest pain, and 1.5 percent of these patients will have unstable angina or acute myocardial infarction. The initial goal in patients presenting with chest pain is to determine if the patient needs to be referred for further testing to rule in or out acute coronary syndrome and myocardial infarction. The physician should consider patient characteristics and risk factors to help determine initial risk. Twelve-lead electrocardiography is typically the test of choice when looking for ST segment changes, new-onset left bundle branch block, presence of Q waves, and new-onset T wave inversions. For persons in whom the suspicion for ischemia is lower, other diagnoses to consider include chest wall pain/costochondritis (localized pain reproducible by palpation), gastroesophageal reflux disease (burning retrosternal pain, acid regurgitation, and a sour or bitter taste in the mouth), and panic disorder/anxiety state. Other less common but important diagnostic considerations include pneumonia (fever, egophony, and dullness to percussion), heart failure, pulmonary embolism (consider using the Wells criteria), acute pericarditis, and acute thoracic aortic dissection (acute chest or back pain with a pulse differential in the upper extremities). Persons with a higher likelihood of acute coronary syndrome should be referred to the emergency department or hospital.

PMID: 23418761 [PubMed - in process]

Diagnosis and management of pulmonary embolism.

BMJ. 2013;346:f757

Authors: Lapner ST, Kearon C

PMID: 23427133 [PubMed - in process]