Thread by @TWDFNR

1/
Why is "Routine Echocardiography in Hemodynamically Stable Patients with Acute Pulmonary Embolism" a #TWDFNR?

This question was addressed in this month's @JHospMedicine by @PaulBerglMD et al.

Here's a thread to complement their awesome review.

journalofhospitalmedicine.com/jhospmed/artic…

2/
Let's start with a case and question. The case is taken from the review by @PaulBerglMD et al. Review it and answer the question in tweet 3.

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Would you order suggest that this patient with stable pulmonary embolism (PE) undergo echocardiography (echo)?

4/
If you answered "yes", your aim may be to further risk stratify this patient.

Some data supports this. One meta-analysis found an OR of 2.29 for short term death in patients with stable PE found to have right ventricular dysfunction (RVD) on echo.

ncbi.nlm.nih.gov/pubmed/24884693

5/
The authors of the @JHospMedicine review identify four reasons why echo for stable PE is a #TWDFNR:
(1) phenotypic expression of RVD varies widely
(2) even with RVD, the adverse event rate is low
(3) RVD on echo adds little over biomarkers
(4) harm may result

6/
For this thread, we'll cover the third argument.

The review is #openaccess and can be read for those who want to read all the arguments presented by @PaulBerglMD et al.

7/
Regarding "RVD vs. biomarkers", one meta-analysis found the following unadjusted ORs for short-term death:

RVD = 2.4
BNP = 9.5*
Troponin = 8.3*
[*the cutoffs varied based on the study]

This suggests that RVD may add little once one has BNP/troponin.

ncbi.nlm.nih.gov/pubmed/18495689

8/
Instead of routinely using echo in stable PE, the authors suggest using validated risk stratification models including the simplified PESI (sPESI) and the eStiMaTe© calculator.

These provide estimates for 30-day mortality.

mdcalc.com/simplified-pes…
riete.org/estimate/

9/
Here are the final set of recommendations offered by @PaulBerglMD, Adrian Umpierrez de Reguero, and Jayshil J Patel.

For the patient in tweet 2, the sPESI and eStiMaTe© predict 30-day mortality rates of 1.1% and 0.4%. Assessing for RVD on echo would not add value.

10/
If you're interested in reading more about why routine echocardiography in hemodynamically stable patients with PE is a #TWDFNR download the open access article at @JHospMedicine

journalofhospitalmedicine.com/jhospmed/artic…