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FACP. Colegio de médicos de Tarragona Nº 4305520 / fgcapriles@gmail.com




Tuesday, August 9, 2016

Controversies in Subsegmental PE

emDocs - August 7, 2016 - Author: Long B - Edited by: Koyfman A
"Pulmonary embolism (PE) is classically a life-threatening diagnosis, often considered in the work-up of patients with chest pain or dyspnea. Initial mortality rates of missed, untreated PE has been quoted as high as 26%, based on a 1960 study. This disease is common, with 400,000 patients affected with nonfatal PE and another 200,000 patients in the U.S. dying each year from this disease. PE is the third most common cause of death in cardiovascular disease after myocardial infarction and stroke.
With this risk of mortality, physicians through the years have been tasked with diagnosing and managing PE. Unfortunately, no individual risk factor, symptom, or clinical sign can definitively diagnose or exclude PE. Thus, evaluation for PE often includes clinical decision rules, laboratory tests, and several imaging modalities. These tools have been developed to provide physicians with avenues for the evaluation and diagnosis of PE. However, the availability of these tests has resulted in increased test use and number of PE diagnoses. In particular, the use of D-dimer and computed tomography pulmonary angiography (CTPA) has remarkably increased. However, mortality from PE has not changed with increased rates of diagnosis. With the increased testing for PE and sensitivity of CTPA, the diagnosis of subsegmental PE and incidental PE is increasing. Controversy currently exists in the use of CTPA for PE and treatment of these lesions. Recent literature and guidelines have sought to answer these questions, illuminating the path for proper diagnosis, evaluation, and management.
CTPA is the first-line imaging modality for PE and has developed the ability to image pulmonary vasculature down to fifth order branches. However, this test is not without risk including radiation, contrast reaction, and contrast nephropathy. With the ever-increasing imaging capability of CTPA, the diagnosis of incidental and subsegmental PE is increasing, Controversy has occurred concerning the potential dangers of these lesions and whether treatment is warranted. The literature differs in demonstrating harm of SSPE. Fortunately, the ACCP recently released updated guidelines for the treatment of SSPE taking into account the patient, the scan, and other imaging modalities. Ultimately, providers must reign in testing and use risk stratification, in association with shared decision making, in the evaluation and treatment of PE."