Thread by @AkivaRosenzveig

1/ A 40-year-old man presents with Dyspnea and this finding on CTPA ⬇️. How do we treat?

WOAHHH hold your 🐎! Although the CT is black & white, the approach to pulmonary embolism (PE) is more nuanced

Let's talk about PE diagnosis - A @CardioNerds 🧵...

@PERTConsortium #PERT

2/ Let’s start with PE Epidemiology 🧮

👉3rd leading cause of CV mortality
👉Annual incidence worldwide is 1 in 1000
👉120 per 100,000 in US
👉PE diagnosis continues to 📈

ahajournals.org/doi/10.1161/CI…

3/ Let’s follow the 5️⃣ steps of PE management:

1️⃣Suspect PE
2️⃣Estimate Risk of PE
3️⃣Diagnose with imaging
4️⃣Risk Stratification
5️⃣Treatment

Shoutout to @AmitGoyalMD for this framework

4/ ⚠️Risk Factors⚠️

Strong (OR>10)
▶️Major trauma or surgery
▶️Spinal cord injury
▶️Hip/knee replacement
▶️Hip/leg fracture

Moderate (OR 2-9)
▶️Malignancy
▶️Peripartum
▶️Previous VTE
▶️Thrombophilia

Weak (OR <2)
▶️Immobility
▶️Obesity
▶️Varicose Veins

ahajournals.org/doi/full/10.11…

5/ Common symptoms of PE:

▶️Fatigue
▶️Dyspnea
▶️Chest Pain
▶️Syncope/Presyncope
▶️Cough
▶️Diaphoresis
▶️Fever
▶️Hemoptysis

The symptoms are quite nonspecific so how do we make the diagnosis❓

6/ Diagnosis

⭐️if “clinical gestalt” <15%, the PERC rule can be used to ❌ PE
In the PROPER trial, PERC was non-inferior & required 10% fewer imaging studies vs standard care
jamanetwork.com/journals/jama/…

⭐️if “clinical gestalt” >15% or PERC positive....

7/ Wells score (≤4) or Revised Geneva score (≤10)
➕
D-Dimer below threshold
🟰
❌ PE (sens 98-99%, spec 37-40%)

jamanetwork.com/journals/jama/…

8/ If:

▶️D-dimer is above the threshold
▶️Clinical gestalt is high (>40%)
▶️Wells score >6
▶️Revised geneva score > 10

Next step: imaging 🩻

👀 this Dx strategy flow chart from Freund et al.
jamanetwork.com/journals/jama/…

9/ Main imaging modalities:

👉CTPA
▶️evidence of filling defect ➡️ sensitivity of 94% for PE
▶️can look for other pathology
👉V/Q scan
▶️not as available
▶️lower sensitivity for PE (56-98%)
▶️can't ID other pathology

10/ Now that we clinched the Dx, let’s risk stratify

▶️sPESI, RV:LV ratio on imaging, Biomarkers
▶️Out with massive/submassive. In with high, intermediate, and low risk per the AHA 2019 consensus statement
▶️ESC further stratifies to intermediate-high & intermediate-low risk

11/
⚠️High Risk
▶️New systolic BP <90 mmHg, ≥40 mmHg ⬇️ for ≥15 min
▶️Pressors
▶️Cardiac arrest

⚠️Intermediate ⬆️-risk
▶️sPESI ≥1
▶️RV/LV ratio >0.9 &⬆️biomarkers

⚠️Intermediate ⬇️-risk
▶️sPESI ≥1
▶️RV/LV ratio >0.9 OR ⬆️biomarkers

⚠️Low Risk
▶️lacks criteria for⬆️risk

12/
🛑High Risk
5% of PE
~30% ☠️

🛑Intermediate Risk
35-55% of PE
2-3% 30d ☠️ with up to 15% at 90d when treated with AC 💊 alone

🛑Low Risk
40-60% of PE
30d ☠️ = 1%

13/ How do we treat these patients❓
Stay tuned for part 2️⃣ as we venture into the 🌎 of Rx and escalation of care therapies.

Major 🙏 to @dinubalanescu for his guidance and @AmitGoyalMD @TDonisan and @Gurleen_Kaur96 for reviewing!!

Until then 👋
#CardioTwitter #ACCMedStudent