Advertisement

Internal and Emergency Medicine

, Volume 13, Issue 4, pp 567–574 | Cite as

Diagnostic accuracy of focused cardiac and venous ultrasound examinations in patients with shock and suspected pulmonary embolism

  • Peiman Nazerian
  • Giovanni Volpicelli
  • Chiara Gigli
  • Alessandro Lamorte
  • Stefano Grifoni
  • Simone Vanni
EM - ORIGINAL

Abstract

Evaluating the diagnostic performance of focused cardiac ultrasound (US) alone and combination with venous US in patients with shock and suspected pulmonary embolism (PE). Consecutive adult patients with shock and suspected PE, presenting to two Italian emergency departments, were included. Patients underwent cardiac and venous US at presentation with the aim of detecting right ventricular (RV) dilatation and proximal deep venous thrombosis (DVT). Final diagnosis of PE was based on a second level diagnostic test or autopsy. Among the 105 patients included in the study, 43 (40.9%) had a final diagnosis of PE. Forty-seven (44.8%) patients showed RV dilatation and 27 (25.7%) DVT. Sensitivity and specificity of cardiac US were 91% (95% CI 80–97%) and 87% (95% CI 80–91%), respectively. Venous US showed a lower sensitivity (56%, 95% CI 45–60%) but higher specificity (95%, 95% CI 88–99%) than cardiac US (both p < 0.05). When cardiac and venous US were both positive (22 out of 105 patients, 21%) the specificity increased to 100% (p < 0.01 vs cardiac US), whereas when at least one was positive (54 out of 105 patients, 51%) the sensitivity increased to 95% (p = 0.06 vs cardiac US). Focused cardiac US showed good but not optimal sensitivity and specificity for the diagnosis of PE in patients presenting with shock. Venous US significantly increased specificity of cardiac US, and the diagnosis of PE can be certain when both tests are positive or reasonably excluded when negative.

Keywords

Pulmonary embolism Shock Right ventricular dysfunction Ultrasound Echocardiography Venous compression ultrasonography Diagnostic accuracy 

Notes

Acknowledgements

No sponsor funded the study.

Compliance with ethical standards

Conflict of interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.

Human and animal rights

This is a prospective diagnostic accuracy study. Study patients were recruited from June 2012 to April 2015 in the Emergency Departments (EDs) of two Italian university hospitals with an annual census of 50,000 and 100,000 visits, respectively. The local ethics committee approved the study.

Informed consent

Written informed consent was obtained for inclusion in the study.

Supplementary material

Supplementary material 1 (M4V 2875 kb)

Supplementary material 2 (M4V 3048 kb)

References

  1. 1.
    Konstantinides SV, Torbicki A, Agnelli G et al (2014) Guidelines on the diagnosis and management of acute pulmonary embolism: the task force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology. Eur Heart J 35:3033–3080CrossRefPubMedGoogle Scholar
  2. 2.
    Jaff MR, McMurtry S, Archer SL et al (2011) Management of massive and submassive pulmonary embolism, ilio-femoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation 123:1788–1830CrossRefPubMedGoogle Scholar
  3. 3.
    Raja AS, Greenberg JO, Qaseem A et al (2015) Evaluation of patients with suspected acute pulmonary embolism: best practice advice from the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med 163:701–711CrossRefPubMedGoogle Scholar
  4. 4.
    Moore CL, Copel JA (2011) Point-of-care ultrasonography. N Engl J Med 364:749–757CrossRefPubMedGoogle Scholar
  5. 5.
    Neskovic AN, Hagendorff A, Lancellotti P et al (2013) Emergency echocardiography: the European Association of Cardiovascular Imaging recommendations. Eur Heart J Cardiovasc Imaging 14:1–11CrossRefPubMedGoogle Scholar
  6. 6.
    Kucher N, Luder CM, Dörnhöfer T et al (2003) Novel management strategy for patients with suspected pulmonary embolism. Eur Heart J 24:366–376CrossRefPubMedGoogle Scholar
  7. 7.
    O’Rourke RA, Dell’Italia LJ (2004) Diagnosis and management of right ventricular myocardial infarction. Curr Probl Cardiol 29:6–47CrossRefPubMedGoogle Scholar
  8. 8.
    Vieillard-Baron A, Jardin F (2003) Why protect the right ventricle in patients with acute respiratory distress syndrome? Curr Opin Crit Care 9:15–21CrossRefPubMedGoogle Scholar
  9. 9.
    Maeder M, Fehr T, Rickli H, Ammann P (2006) Sepsis-associated myocardial dysfunction: diagnostic and prognostic impact of cardiac troponins and natriuretic peptides. Chest 129:1349–1366CrossRefPubMedGoogle Scholar
  10. 10.
    Parker MM, McCarthy KE, Ognibene FP, Parrillo JE (1990) Right ventricular dysfunction and dilatation, similar to left ventricular changes, characterize the cardiac depression of septic shock in humans. Chest 97:126–131CrossRefPubMedGoogle Scholar
  11. 11.
    Grifoni S, Olivotto I, Cecchini P et al (1998) Utility of an integrated clinical, echocardiographic, and venous ultrasonographic approach for triage of patients with suspected pulmonary embolism. Am J Cardiol 82:1230–1235CrossRefPubMedGoogle Scholar
  12. 12.
    The Steering Committee (2012) Single-bolus tenecteplase plus heparin compared with heparin alone for normotensive patients with acute pulmonary embolism who have evidence of right ventricular dysfunction and myocardial injury: rationale and design of the Pulmonary Embolism Thrombolysis (PEITHO) trial. Am Heart J 163:33–38CrossRefGoogle Scholar
  13. 13.
    Nazerian P, Vanni S, Volpicelli G et al (2014) Accuracy of point-of-care multiorgan ultrasonography for the diagnosis of pulmonary embolism. Chest 145:950–957CrossRefPubMedGoogle Scholar
  14. 14.
    Prandoni P, Cogo A, Bernardi E et al (1993) A simple ultrasound approach for detection of recurrent proximal-vein thrombosis. Circulation 88:1730–1735CrossRefPubMedGoogle Scholar
  15. 15.
    Magazzini S, Vanni S, Toccafondi S et al (2007) Duplex ultrasound in the emergency department for the diagnostic management of clinically suspected deep vein thrombosis. Acad Emerg Med 14:216–220CrossRefPubMedGoogle Scholar
  16. 16.
    Hawass N (1997) Comparing the sensitivities and specificities of two diagnostic procedures performed on the same group of patients. Br J Radiol 70:360–366CrossRefPubMedGoogle Scholar
  17. 17.
    Stein PD, Willis PW, DeMets DL (1981) History and physical examination in acute pulmonary embolism in patients without preexisting cardiac or pulmonary disease. Am J Cardiol 47:218–223CrossRefPubMedGoogle Scholar
  18. 18.
    Miniati M, Prediletto R, Formichi B et al (1999) Accuracy of clinical assessment in the diagnosis of pulmonary embolism. Am J Respir Crit Care Med 159:864–871CrossRefPubMedGoogle Scholar
  19. 19.
    Kearon C (2003) Diagnosis of pulmonary embolism. CMAJ 168:183–194PubMedPubMedCentralGoogle Scholar
  20. 20.
    Wells PS, Anderson DR, Rodger M et al (2001) Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer. Ann Intern Med 135:98–107CrossRefPubMedGoogle Scholar
  21. 21.
    Le Gal G, Righini M, Roy PM et al (2006) Prediction of pulmonary embolism in the emergency department: the revised Geneva score. Ann Intern Med 144:165–171CrossRefPubMedGoogle Scholar
  22. 22.
    Haddad F, Doyle R, Murphy DJ, Hunt SA (2008) Right ventricular function in cardiovascular disease, part II: pathophysiology, clinical importance, and management of right ventricular failure. Circulation 117:1717–1731CrossRefPubMedGoogle Scholar
  23. 23.
    Joseph MX, Disney PJ, Da Costa R, Hutchison SJ (2004) Transthoracic echocardiography to identify or exclude cardiac cause of shock. Chest 126:1592–1597CrossRefPubMedGoogle Scholar
  24. 24.
    Orme RMLE, Oram MP, McKinstry CE (2009) Impact of echocardiography on patient management in the intensive care unit: an audit of district general hospital practice. Br J Anaesth 102:340–344CrossRefPubMedGoogle Scholar
  25. 25.
    Beaulieu Y (2007) Bedside echocardiography in the assessment of the critically ill. Crit Care Med 35:S235–S249CrossRefPubMedGoogle Scholar
  26. 26.
    Lesser BA, Leeper KV, Stein PD et al (1992) The diagnosis of acute pulmonary embolism in patients with chronic obstructive pulmonary disease. Chest 102:17–22CrossRefPubMedGoogle Scholar
  27. 27.
    Kasper W, Geibel A, Tiede N et al (1993) Distinguishing between acute and subacute massive pulmonary embolism by conventional and Doppler echocardiography. Br Heart J 70:352–356CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Rizkallah J, Man SF, Sin DD (2009) Prevalence of pulmonary embolism in acute exacerbations of COPD: a systematic review and metaanalysis. Chest 135:786–793CrossRefPubMedGoogle Scholar
  29. 29.
    Nickerson RS (1998) Confirmation bias: a ubiquitous phenomenon in many guises. Rev Gen Psychol 2:175–220CrossRefGoogle Scholar
  30. 30.
    Becattini C, Agnelli G, Germini F, Vedovati MC (2014) Computed tomography to assess risk of death in acute pulmonary embolism: a meta-analysis. Eur Respir J 43:1678–1690CrossRefPubMedGoogle Scholar
  31. 31.
    Ferrari E, Benhamou M, Berthier F, Baudouy M (2005) Mobile thrombi of the right heart in pulmonary embolism: delayed disappearance after thrombolytic treatment. Chest 127:1051–1053CrossRefPubMedGoogle Scholar
  32. 32.
    Via G, Hussain A, Wells M et al (2014) Committee on Focused Cardiac UltraSound (ILC-FoCUS). International Conference on Focused Cardiac UltraSound (IC-FoCUS). International evidence-based recommendations for focused cardiac ultrasound. J Am Soc Echocardiogr 27:1–33CrossRefGoogle Scholar

Copyright information

© SIMI 2017

Authors and Affiliations

  1. 1.Department of Emergency MedicineCareggi University HospitalFlorenceItaly
  2. 2.Department of Emergency MedicineSan Luigi Gonzaga University HospitalTurinItaly

Personalised recommendations