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Assessing the severity of pulmonary embolism among patients in the emergency department: Utility of RV/LV diameter ratio.

ABSTRACT: BACKGROUND:Acute pulmonary embolism (APE) is a major cause of death from cardiovascular disease. Right ventricular systolic dysfunction (RVD) caused by APE is closely related to a poor outcome. Early risk stratification of APE is a vital step in prognostic assessment. The objective of this study was to investigate the usefulness of computed tomographic pulmonary angiography (CTPA) measured right ventricular (RV)/ left ventricular (LV) diameter ratio by the emergency department (ED) specialists for early risk stratification of APE patients in ED. METHODS:The retrospective data of 229 APE patients were reviewed. Two ED specialists measured both RV and LV diameters on a single transverse scan perpendicular to the long axis of the heart. The patients were divided into two groups, RV/LV diameter ratio <1 and ratio >1. CTPA measured RV/LV diameter ratio were analyzed and compared with sPESI score, cardiac biomarkers such as N-Terminal Pro-B-Type Natriuretic Peptide (NT-pro-BNP), high sensitivity cardiac troponin T (hs-cTnT), and RVD measured by echocardiography (Echo). RESULTS:The mean age in RV/LV > 1 group was significantly higher than that of the other group (67.81±2.7 years vs. 60.68±3.2 years). Also, there were more hypertension patients (44.4% vs. 33.3%), and mean arterial pressure (MAP) was lower. A significantly higher ICU admission rate (28.05% vs. 11.61%) was shown in RV/LV >1 group, and five patients expired only in RV/LV > 1 group. RVD by Echo demonstrated the highest sensitivity, specificity, and negative predictive value (NPV) (values of 94.3%, 81.1%, 95.5%). RV/LV >1 diameter ratio by CTPA showed usefulness equivalent to cardiac biomarkers. RV/LV >1 patients' cardiac enzymes were higher, and there were more RVD in RV/LV >1 group. CONCLUSION:Simple measurement of RV/LV diameter ratio by ED specialist would be a help to the clinicians in identifying and stratifying the risk of the APE patients presenting in the ED.

SUBMITTER: Cho SU

PROVIDER: S-EPMC7676654 | biostudies-literature | 2020

REPOSITORIES: biostudies-literature

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Assessing the severity of pulmonary embolism among patients in the emergency department: Utility of RV/LV diameter ratio.

Cho Sung-Uk SU Cho Young-Duck YD Choi Sung-Hyuk SH Yoon Young-Hoon YH Park Jong-Hak JH Park Sung-Joon SJ Lee Eu-Sun ES

PloS one 20201119 11

<h4>Background</h4>Acute pulmonary embolism (APE) is a major cause of death from cardiovascular disease. Right ventricular systolic dysfunction (RVD) caused by APE is closely related to a poor outcome. Early risk stratification of APE is a vital step in prognostic assessment. The objective of this study was to investigate the usefulness of computed tomographic pulmonary angiography (CTPA) measured right ventricular (RV)/ left ventricular (LV) diameter ratio by the emergency department (ED) speci ...[more]

PMID: 33211719

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Project description:IntroductionMany emergency department (ED) patients with acute pulmonary embolism (PE) who meet low-risk criteria may be eligible for a short length of stay (LOS) (<24 hours), with expedited discharge home either directly from the ED or after a brief observation or hospitalization. We describe the association between expedited discharge and site of discharge on care satisfaction and quality of life (QOL) among patients with low-risk PE (PE Severity Index [PESI] Classes I-III).MethodsThis phone survey was conducted from September 2014 through April 2015 as part of a retrospective cohort study across 21 community EDs in Northern California. We surveyed low-risk patients with acute PE, treated predominantly with enoxaparin bridging and warfarin. All eligible patients were called 2-8 weeks after their index ED visit. PE-specific, patient-satisfaction questions addressed overall care, discharge instruction clarity, and LOS. We scored physical and mental QOL using a modified version of the validated Short Form Health Survey. Satisfaction and QOL were compared by LOS. For those with expedited discharge, we compared responses by site of discharge: ED vs. hospital, which included ED-based observation units. We used chi-square and Wilcoxon rank-sum tests as indicated.ResultsSurvey response rate was 82.3% (424 of 515 eligible patients). Median age of respondents was 64 years; 47.4% were male. Of the 145 patients (34.2%) with a LOS<24 hours, 65 (44.8%) were discharged home from the ED. Of all patients, 89.6% were satisfied with their overall care and 94.1% found instructions clear. Sixty-six percent were satisfied with their LOS, whereas 17.5% would have preferred a shorter LOS and 16.5% a longer LOS. There were no significant differences in satisfaction between patients with LOS<24 hours vs. ≥24 hours (p>0.13 for all). Physical QOL scores were significantly higher for expedited-discharge patients (p=0.01). Patients with expedited discharge home from the ED vs. the hospital had no significant difference in satisfaction (p>0.20 for all) or QOL (p>0.19 for all).ConclusionED patients with low-risk PE reported high satisfaction with their care in follow-up surveys. Expedited discharge (<24 hours) and site of discharge were not associated with differences in patient satisfaction.

Project description:Background: Right ventricular (RV) and left ventricular (LV) myocardium differ in their response to pressure-overload hypertrophy (POH). In this report we use microarray and proteomic analyses to identify pathways modulated by LV-, and RV-POH in the immature heart. Methods: Newborn New Zealand White rabbits underwent banding of the descending thoracic aorta (LV-POH; n=6). RV-POH was achieved by banding the pulmonary artery (n=6). Sham–control animals (SC; n=6 each) were sham-manipulated. Following 4 (LV-POH) and 6 weeks (RV-POH) recovery, the hearts were removed and matched sample RNA and proteins were isolated for microarray and proteomic analysis. Results: There was no difference in body weight in RV-, LV-POH vs. SC but there was a significant increase vs. SC in RV (3.2±0.8g vs. 1.2±0.3g; P<0.01) and LV weight (7.08±0.6g vs. 4.02±0.2g; P<0.01). Fractional area change (RV-POH) and shortening fraction (LV-POH) decreased significantly (23±6 vs. 47±6 and 21±4 vs.44±2, respectively, P<0.01). Microarray analysis demonstrated that LV-POH enriched pathways for oxidative phosphorylation, mitochondria energy pathways, actin, ILK, hypoxia, calcium and protein kinase-A signalling. RV-POH enriched pathways for cardiac oxidative phosphorylation. Proteomic analysis revealed 19 proteins were uniquely expressed in LV-POH vs. SC. Functional annotation clustering analysis indicated significant enrichment for the mitochondrion, cellular macromolecular complex assembly and oxidative phosphorylation. RV-POH had 15 uniquely expressed proteins vs. SC. Functional annotation clustering analysis indicated significant enrichment in structural constituents of muscle, cardiac muscle tissue development and calcium handling. Conclusion: Our results identify unique transcript and protein expression profiles in LV, RV-POH and provide new insight into the biological basis of ventricular specific hypertrophy. 3 different conditions: PAB-RV vs. Sham-control RV, PAB-RV [test] vs. PAB-LV [control], AOB-LV vs. Sham-control LV.

Project description:BACKGROUND:The goal of these analyses was to determine whether there were systematic differences in Emergency Severity Index (ESI) scores, which are intended to determine priority of treatment and anticipate resource needs, across categories of race and ethnicity, after accounting for patient-presenting vital signs and examiner characteristics, and whether these differences varied among male and female Veterans Affairs (VA) ED patients. METHODS AND FINDINGS:We used a large national database of electronic medical records of ED patients from twenty-two U.S. Department of Veterans Affairs ED stations to determine whether ESI assignments differ systematically by race or ethnicity. Multi-level, random effects linear modeling was used to control for demographic characteristics and patient's vital signs (heart rate, respiratory rate, and pain level), as well as age, gender, and experience of triage nurses. The dataset included 129,991 VA patients presenting for emergency care between 2008 and 2012 (91% males; 61% non-Hispanic White, 28% Black, 7% Hispanic, 2% Asian, <1% American Indian/Alaska Native, 1% mixed ethnicity) and 774 nurses for a total of 359,642 patient/examiner encounters. Approximately 13% of the variance in ESI scores was due to patient characteristics and 21% was due to the nurse characteristics. After controlling for characteristics of nurses and patients, Black patients were assigned less urgent ESI scores than White patients, and this effect was more prominent for Black males compared with Black females. A similar interaction was found for Hispanic males. It remains unclear how these results may generalize to EDs and patient populations outside of the U.S. VA Health Care system. CONCLUSIONS:The findings suggest the possibility that subgroups of VA patients receive different ESI ratings in triage, which may have cascading, downstream consequences for patient treatment quality, satisfaction with care, and trust in the health equity of emergency care.

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Assessing the severity of pulmonary embolism among patients in the emergency department: Utility of RV/LV diameter ratio.

Publications

Assessing the severity of pulmonary embolism among patients in the emergency department: Utility of RV/LV diameter ratio.

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