Embolie pulmonaire-TVP

CONCLUSIONS: In patients with a first episode of unprovoked VTE who completed at least three months of anticoagulant treatment, the risk of recurrent VTE was 10% in the first year after treatment, 16% at two years, 25% at five years, and 36% at 10 years, with 4% of recurrent VTE events resulting in death. These estimates should inform clinical practice guidelines, enhance confidence in counselling patients of their prognosis, and help guide decision making about long term management of unprovoked VTE.

Diagnostic

Comparison of the unstructured clinician gestalt, the wells score, and the revised Geneva score to estimate pretest probability for suspected pulmonary embolism. Penaloza A, Verschuren F, Meyer G, Quentin-Georget S, Soulie C, Thys F, Roy PM. Ann Emerg Med. 2013 Aug;62(2):117-124.e2. doi: 10.1016/j.annemergmed.2012.11.002. Epub 2013 Feb 21. PMID: 23433653.

Comparison of YEARS and Adjust-Unlikely D-dimer Testing for Pulmonary Embolism in the Emergency Department. de Wit K, Al-Haimus F, Hu Y, Ikesaka R, Chan N, Ibrahim Q, Klyn J, Clayton N, Germini F. Ann Emerg Med. 2022 Nov 10:S0196-0644(22)01118-0. doi: 10.1016/j.annemergmed.2022.09.014. Epub ahead of print. PMID: 36371248.

Results: One thousand seven hundred three patients were included, median age 62 (50, 74), 58% female, PE prevalence 8.0%. YEARS sensitivity for PE diagnosis was 92.6% (87.0, 96.0%) and specificity 45.0% (42.5, 47.5%). Adjust-Unlikely sensitivity was 100.0% (97.2, 100.0%) and specificity 32.4% (30.1, 34.8%). Posttest probability of PE in the group of patients with PE excluded by D-dimer between 500 ng/ml and the adjusted limit was 2.8% (1.6, 5.1%) for YEARS and 0.0% (0.0, 2.6%) for the "Adjust-Unlikely" rule.

Conclusion: The "Adjust-Unlikely" rule would modestly reduce imaging and identify all cases of PE. YEARS would substantially reduce imaging but miss 1 in 14 cases of PE.

YEARS Algorithm Versus Wells' Score: Predictive Accuracies in Pulmonary Embolism Based on the Gold Standard CT Pulmonary Angiography. Abdelaal Ahmed Mahmoud M Alkhatip A, Donnelly M, Snyman L, Conroy P, Hamza MK, Murphy I, Purcell A, McGuire D. Crit Care Med. 2020 Feb 19. doi: 10.1097/CCM.0000000000004271. [Epub ahead of print] PMID: 32079894

MEASUREMENTS AND MAIN RESULTS: Of 794 scans, 78 (9.8%) were positive for pulmonary embolism. The YEARS algorithm was more sensitive than the Wells' score (97.44% vs 74.36%) but was less specific (13.97% vs 33.94%). Furthermore, the diagnostic odds ratio of YEARS was higher than Wells' score (6.27 vs 1.48). YEARS provides better negative predictive value (98% vs 92.4%), and both scores have poor positive predictive value (10.9%).

CONCLUSIONS:

Both scores successfully exclude pulmonary embolism, although YEARS has a better negative predictive value. Both exhibit poor positive predictive value.

Diagnosis of Pulmonary Embolism with d-Dimer Adjusted to Clinical Probability. Kearon C, de Wit K, Parpia S, Schulman S, Afilalo M, Hirsch A, Spencer FA, Sharma S, D'Aragon F, Deshaies JF, Le Gal G, Lazo-Langner A, Wu C, Rudd-Scott L, Bates SM, Julian JA; PEGeD Study Investigators. N Engl J Med. 2019 Nov 28;381(22):2125-2134. doi: 10.1056/NEJMoa1909159.PMID: 31774957

CONCLUSIONS: A combination of a low C-PTP and a d-dimer level of less than 1000 ng per milliliter identified a group of patients at low risk for pulmonary embolism during follow-up. (Funded by the Canadian Institutes of Health Research and others; PEGeD ClinicalTrials.gov number, NCT02483442.).

Comparison of the age-adjusted and clinical probability-adjusted D-dimer to exclude pulmonary embolism in the emergency department, Am J Emerg Med. 2018 Jul 30. pii: S0735-6757(18)30633-8. doi: 10.1016/j.ajem.2018.07.053.

Conclusion: The clinical probability-adjusted rule appears to exclude PE in a greater proportion of patients, with a very small reduction in the negative predictive value.

Simplified diagnostic management of suspected pulmonary embolism (the YEARS study): a prospective, multicentre, cohort study. YEARS study group. Lancet. 2017 Jul 15;390(10091):289-297. doi: 10.1016/S0140-6736(17)30885-1. Epub 2017 May 23. Erratum in: Lancet. 2017 Jul 15;390(10091):230

Pregnancy-Adapted YEARS Algorithm for Diagnosis of Suspected Pulmonary Embolism, N Engl J Med. 2019 Mar 21;380(12):1139-1149. doi: 10.1056/NEJMoa1813865.

CONCLUSIONS: Pulmonary embolism was safely ruled out by the pregnancy-adapted YEARS diagnostic algorithm across all trimesters of pregnancy. CT pulmonary angiography was avoided in 32 to 65% of patients.

Outcomes following a negative computed tomography pulmonary angiography according to pulmonary embolism prevalence: a meta‐analysis of the management outcome studies, Belzile D, Jacquet S, Bertoletti L, Lacasse Y1 Lambert C, Lega JC, Provencher S, J Thromb Haemost. 2018 Jun;16(6):1107-1120. doi: 10.1111/jth.14021. Epub 2018 May 17.

Conclusions : The negative predictive value of CTPA for VTE varies according to pretest prevalence of PE, and is likely to be insufficient to safely rule out VTE as a stand‐alone diagnostic test amongst patients at the highest pretest probability of VTE. Prospective studies are required to validate the appropriate diagnostic algorithm for this subgroup of patients. Subgroup analyses suggested that the cumulative occurrence of VTE was related to pretest prevalence of PE, as VTE occurred in 1.8% (95% CI, 0.5–3.7%), 1.4% (95% CI, 0.7–2.3%), 1.0% (95% CI, 0.5–1.8%) and 8.1% (95% CI, 3.5–14.5%) of subgroups of patients with a PE prevalence < 20%, 20–29%, 30–39% and ≥ 40%, respectively.

Performance of the 4-Level Pulmonary Embolism Clinical Probability Score (4PEPS) in the diagnostic management of pulmonary embolism: An external validation study. Stals MAM, Beenen LFM, Coppens M, et al. Thromb Res. 2023 Sep 20;231:65-75. doi: 10.1016/j.thromres.2023.09.010. (Original study)

PERC Score:

Prospective multicenter evaluation of the pulmonary embolism rule-out criteria, J Thromb Haemost. 2008 May;6(5):772-80. doi: 10.1111/j.1538-7836.2008.02944.x. Epub 2008 Mar 3

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PESI Score:

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D-dimères selon l’âge : Age-Adjusted D-Dimer Cutoff Levels to Rule Out Pulmonary Embolism, The ADJUST-PE Study, JAMA. 2014;311(11):1117-1124. doi:10.1001/jama.2014.2135

Investigation supplémentaire

Cancer Screening in Patients with Unprovoked Thromboembolism: How to do it and Who Benefits? Ferreira F, Pereira J, Lynce A, Nunes Marques J, Martins A. Cureus. 2020 Feb 10;12(2):e6934. doi: 10.7759/cureus.6934. PMID: 32051805; PMCID: PMC7011576.