Adverse Clinical Outcomes Among Patients With Acute Low-risk Pulmonary Embolism and Concerning Computed Tomography Imaging Findings

Q: What are the key findings of this study?

Concerning CTPE findings in patients with low-risk acute PE were not associated with 30-day mortality (0% vs 2.2% without concerning findings) despite lower ED discharge (2.0% vs 7.8%, P=0.01).

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Acute pulmonary embolism (PE) (n=817). Intervention: Concerning computed tomography pulmonary embolism (CTPE) findings in low-risk PE (bilateral central embolus, RV-to-LV ratio >1.0, RV enlargement, septal abnormality, or pulmonary infarction) vs. Low-risk PE without concerning CTPE findings (and high-risk PE by PESI class III-V). Primary outcome: All-cause mortality at 30 days (p=<0.001).

Q: What does this research mean for the field?

In emergency department patients with acute low-risk pulmonary embolism, concerning computed tomography findings are associated with higher hospitalization and resource utilization but not with increased short-term adverse clinical outcomes or mortality. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Q: What question did this study set out to answer?

To assess whether concerning computed tomography findings are associated with adverse clinical outcomes and treatment decisions in emergency department patients with acute, low-risk pulmonary embolism.

Connor O’Hare; Kelsey A. Grace; William J. Schaeffer; S. Nabeel Hyder; Michael D. Stover; Amber Liles; Minhaj S. Khaja; James A. Cranford; Keith E. Kocher; Geoffrey D. Barnes; Colin F. Greineder

doi:10.1001/jamanetworkopen.2023.11455

May 31, 2023JAMA Network OpenOpen Access

Adverse Clinical Outcomes Among Patients With Acute Low-risk Pulmonary Embolism and Concerning Computed Tomography Imaging Findings

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Key result

Concerning CT findings in low-risk PE show no link to 30-day mortality despite fewer ED discharges.

P<0.001
n=817

Figures

Why the study?

Most ED patients with acute PE are hospitalized despite guidelines recommending outpatient care for low-risk cases, potentially due to clinician concern over CTPE findings perceived as high risk but excluded from risk stratification tools.

Are concerning computed tomography pulmonary embolism (CTPE) imaging findings associated with short-term all-cause mortality, hospitalization, and resource utilization in emergency department patients with acute low-risk pulmonary embolism?

Key Points

To assess whether concerning computed tomography findings are associated with adverse clinical outcomes and treatment decisions in emergency department patients with acute, low-risk pulmonary embolism.
Cohort study analyzing a registry of 817 adult patients diagnosed with acute pulmonary embolism in an academic medical center emergency department between October 2016 and December 2019.
Patients were stratified by Pulmonary Embolism Severity Index (PESI) score into low-risk (n=331) and high-risk (n=486) groups.
Low-risk cases were evaluated for five concerning CT findings: bilateral central embolus, RV-to-LV ratio >1.0, RV enlargement, septal abnormality, or pulmonary infarction.
All-cause 30-day mortality was 0% (0 of 151) in low-risk patients with concerning CT findings vs 2.2% (4 of 180) in low-risk patients without them and 18.1% (88 of 486) in the high-risk group (P < .001).
Low-risk patients with concerning CT findings were less frequently discharged from the emergency department than low-risk patients without them (2.0% [3 of 151] vs 7.8% [14 of 180]; P = .01).
Low-risk patients with concerning CT findings underwent more frequent echocardiography (57.6% [87 of 151] vs 27.2% [49 of 180]; P < .001) and pulmonary embolism response team activation (22.5% [34 of 151] vs 6.1% [11 of 180]; P < .001).

Study Design

Type

Cohort (n=817)

Blinding

Blinding of reviewers to study hypothesis

Multicenter

No

Structured PICO

Are concerning computed tomography pulmonary embolism (CTPE) imaging findings associated with short-term all-cause mortality, hospitalization, and resource utilization in emergency department patients with acute low-risk pulmonary embolism?

P

Population

817 adults presenting to a single US academic emergency department with acute pulmonary embolism (median age 58 years, 51.0% female, 331 low-risk and 486 high-risk by PESI score) followed for 30 days.

E

Exposure

Presence of >=1 concerning finding on PE-protocol computed tomography (CTPE) among low-risk PE patients (n=151): (1) bilateral central embolus (saddle or main pulmonary arteries), (2) RV-to-LV ratio >1.0, (3) RV enlargement, (4) septal abnormality consistent with RV pressure overload, or (5) pulmonary infarction.

C

Comparator

Low-risk PE patients without concerning CTPE findings (n=180) and high-risk PE patients (PESI class III-V, n=486).

O

Outcome

All-cause mortality at 7 and 30 days after PE diagnosis, verified using the State of Michigan Death Index.hard clinical

Main Result

Absolute Event Rate: 0% vs 2.2%

p-value: p=<0.001

In patients with acute low-risk pulmonary embolism by PESI score, concerning CT imaging findings (such as RV strain or central clot burden) were not associated with 30-day mortality or ICU admission, despite driving higher rates of hospitalization, echocardiography, and PERT activation.

Limitations

Primary outcome was uncommon, so the study may be underpowered to detect modest differences between groups.
Retrospective design and limited to a single academic tertiary care center.
Cohort had limited racial and ethnic diversity.
Focused on concerning CTPE findings rather than ultrasonographic findings (formal TTE was infrequently completed during ED evaluation, and POCUS had inconsistent operator training/documentation).
Limited to short-term clinical outcomes (7 and 30 days) and did not address bleeding risk or longer-term endpoints like chronic thromboembolic pulmonary hypertension.
Primary outcome was uncommon, potentially underpowering the study to detect modest differences between groups
Retrospective single-center design at an academic tertiary health care center
Limited racial and ethnic diversity in the cohort
Focus on CTPE findings rather than ultrasonographic findings, with infrequent ED TTE and inconsistent POCUS documentation
Limited to short-term clinical outcomes (7 and 30 days) and did not evaluate major bleeding or long-term sequelae

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Implication

Concerning CTPE findings should not yet alter ED discharge in low-risk PE; leaves open their incremental value over PESI for risk stratification.

Abstract

Importance: Most patients presenting to US emergency departments (EDs) with acute pulmonary embolism (PE) are hospitalized, despite evidence from multiple society-based guidelines recommending consideration of outpatient treatment for those with low risk stratification scores. One barrier to outpatient treatment may be clinician concern regarding findings on PE-protocol computed tomography (CTPE), which are perceived as high risk but not incorporated into commonly used risk stratification tools. Objective: To evaluate the association of concerning CTPE findings with outcomes and treatment of patients in the ED with acute, low-risk PE. Design, Setting, and Participants: This cohort study used a registry of all acute PEs diagnosed in the adult ED of an academic medical center from October 10, 2016, to December 31, 2019. Acute PE cases were divided into high- and low-risk groups based on PE Severity Index (PESI) class alone or using a combination of PESI class and biomarker results. The low-risk group was further divided based on the presence of concerning CTPE findings: (1) bilateral central embolus, (2) right ventricle-to-left ventricle ratio greater than 1.0, (3) right ventricle enlargement, (4) septal abnormality, or (5) pulmonary infarction. Data analysis was conducted from June to October 2022. Main Outcomes and measures: The primary outcome was all-cause mortality at 7 and 30 days. Secondary outcomes included hospitalization, length of stay, need for intensive care, use of echocardiography and/or bedside ultrasonography, and activation of the PE response team (PERT) . Results: Of 817 patients (median [IQR] age, 58 [47-71] years; 417 (51.0%) female patients; 129 [15.8%] Black and 645 [78.9%] White patients) with acute PEs, 331 (40.5%) were low risk and 486 (59.5%) were high risk by PESI score. Clinical outcomes were similar for all low-risk patients, with no 30-day deaths in the low-risk group with concerning CTPE findings (0 of 151 patients) vs 4 of 180 (2.2%) in the low-risk group without concerning CTPE findings and 88 (18.1%) in the high-risk group (P < .001). Low-risk patients with concerning CTPE findings were less frequently discharged from the ED than those without concerning CTPE findings (3 [2.0%] vs 14 [7.8%]; P = .01) and had more frequent echocardiography (87 [57.6%] vs 49 [27.2%]; P < .001) and PERT activation for consideration of advanced therapies (34 [22.5%] vs 11 [6.1%]; P < .001). Conclusions and Relevance: In this single-center study, CTPE findings widely believed to confer high risk were associated with increased hospitalization and resource utilization in patients with low-risk PE but not short-term adverse clinical outcomes.

Discussion

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Cite This Study

O’Hare et al. (2023) conducted a cohort in Acute pulmonary embolism (PE) (n=817). Concerning computed tomography pulmonary embolism (CTPE) findings in low-risk PE (bilateral central embolus, RV-to-LV ratio >1.0, RV enlargement, septal abnormality, or pulmonary infarction) vs. Low-risk PE without concerning CTPE findings (and high-risk PE by PESI class III-V) was evaluated on All-cause mortality at 30 days (p=<0.001). Concerning CTPE findings in patients with low-risk acute PE were not associated with 30-day mortality (0% vs 2.2% without concerning findings) despite lower ED discharge (2.0% vs 7.8%, P=0.01).

synapsesocial.com/papers/6a7b8c6d0449e558d7c28547 https://doi.org/10.1001/jamanetworkopen.2023.11455

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Adverse Clinical Outcomes Among Patients With Acute Low-risk Pulmonary Embolism and Concerning Computed Tomography Imaging Findings

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Adverse Clinical Outcomes Among Patients With Acute Low-risk Pulmonary Embolism and Concerning Computed Tomography Imaging Findings

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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