Talk:Pulmonary embolism/Archive 1

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INR range

From "Treatment": "In PE, INRs between 2.5 and 3.5 are considered ideal." It's really that simple, is it? :) Gonegonegone 21:30, 5 Dec 2004 (UTC)

What are you suggesting? JFW | T@lk 22:57, 5 Dec 2004 (UTC)
My impression was that depending on the circs surrounding the PE (first, later, on or off warfarin at the time, what [if known!] is the background condition, and so on) it might well vary, so it would be hard to say "In PE" as if there was one universal standard ideal for all PEs. OK so I am not a medic, but a mere patient - but my own experience has been that of going from 3.0-4.5 to 3.0-4.0 to 2.5-3.5 as varying risk factors have been looked at, i.e. I have bled less or more. I wasn't sure that it was not a bit too simple to say "are considered ideal" so straightforwardly. But you may know otherwise, what with having all those letters after your name <g>, so please edit or leave as you see fit. I'm hoping to get more uninvolved from WP anyway so I will probably be quite happy with whatever you do! :) Gonegonegone 23:33, 5 Dec 2004 (UTC)
You may be right. I'm gonna look into it. Please do not get uninvolved... Wikipedia needs you! :-) JFW | T@lk 08:22, 6 Dec 2004 (UTC)

Traumatic PE

Gronky (talk · contribs) linked to a case series of 44 detainees of the US army, one of whom had reportedly died of PE after blunt force injury[1]. I'm really not sure what the point is here (apart from making the army look bad), but of the millions of people suffering PEs annually, very few have this as a result of injury. In fact, the textbooks only mention PE after trauma if there has been immobilisation or fat embolism from fractures of the long bones (or air embolism from jugular vein tears). I dispute the need of including this one case just to make a point. JFW | T@lk 23:47, 27 October 2005 (UTC)

Hi Jfdwolff (talk · contribs). The article I linked to gives a medical description of how a pulmonary embolism occurred and caused death. Will you revert if it's re-added without mentioning that the US Army was involved? I thought the context was useful, but it's not the point. This particular case is interesting because its cause is not otherwise mentioned in the articled: a person getting a severe beating. It will be hard to find an example of such a case that doesn't make someone look bad. I think more examples would be useful, but I only happened across one. Gronky 00:24, 28 October 2005 (UTC)
Actually, I don't have the energy. I probably won't come back to this for a few weeks. Maybe a section on "Available medical records of deaths by PE" would be better. Or whatever you think is best. Gronky 00:38, 28 October 2005 (UTC)

The cause and mechanism of death in PE is thoroughly understood, and needs little outside support. The link you've provided describes an oddity that has not caused much furore in the medical literature. What should the aim of the link be? JFW | T@lk 02:05, 28 October 2005 (UTC)

I reviewed the pathology report full PDF. The examiner does not propose the mechanism of the PE, and I'd say the causality is somewhat doubtful. It seems to suggest that if you kick someone enough, they get blood clots in the lung - how? JFW | T@lk 02:22, 28 October 2005 (UTC)

Wells score

The Wells score is by far the most popular scoring system, especially when the D-dimer is being used. Reference: Wells PS, Anderson DR, Rodger M, Ginsberg JS, Kearon C, Gent M, et al. Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED d-dimer. Thromb Haemost 2000;83:416-20.

Suspected DVT 3.0
Alternative diagnosis less likely than PE 3.0
HR >100 beats per minute 1.5
Immobilization or surgery in the previous four weeks 1.5
Previous DVT or PE 1.5
Hemoptysis 1.0
Malignancy (treatment, treated in the past six months or palliative) 1.0
Interpretation: <2 points low, 2 to 6 points moderate, >6 points high

Good idea? JFW | T@lk 18:38, 31 July 2006 (UTC)

I think that reference 6 referes to DVT and not specifically PE, small point but there you go! Dcs26 12:24, 12 December 2006 (UTC)

Curious

No mention of putting a filter into the veinous return into the heart as a treatment? That's what happened to "a friend of mine".. (within a couple of hours of being resuscitated from multiple PEs on both lungs, including PEs on both main pulmonary arteries). This was in a cost-conscious UK NHS hospital after CT and then ultrasounding the source clots. They seem to be fairly common: the surgeon said he had put in about fifty, although if they can they wait for the TPA to clear out of the system before the intervention. --BozMo talk 08:33, 19 February 2007 (UTC)

Interesting point, and we should probably cover inferior vena cava filters in this article. There is not a great deal of evidence for the use of filters in those with emboli from leg DVTs; standard anticoagulation treatment is not inferior to filters, and the filters themselves can generate thrombi, dislodge, get infected and heaven knows what else. They are useful for those who make emboli despite high-dose (INR 3.0-4.0) warfarin or those who have a contraindication to anticoagulation (e.g. previous haemorrhagic CVA). JFW | T@lk 10:45, 25 February 2007 (UTC)
Thanks for the correct article name, I hadn't see it. Actually with me it was an emergency measure. I had emboli on both lungs and was still shedding clots off the left knee, despite TPA and heparin. They thought one more clot on the lungs would probably be one too many. The consenting consultant did point out the lack of evidence base, of course. All UK NHS so they are pretty cost conscientious and don't go for unnecessary interventions. The filter is designed to come out within 15 days but the annual failure rate is about 3% (so not too bad although given I am 41 it is pretty certain to fail eventually) --BozMo talk 11:45, 25 February 2007 (UTC)

Risk stratification

There's much talk in the literature on risk stratification. With RV dysfunction as a negative prognostic indicator, some studies use cardiac biomarkers (troponin I and BNP) to stratify. We should probably cover this; I personally feel that no person with a confirmed (or highly suspected) PE should leave hospital without an echocardiogram. JFW | T@lk 10:48, 25 February 2007 (UTC)

Symptoms

doi:10.1016/j.amjmed.2007.03.024 (PIOPED II) reinforces the message that symptoms do not keep trend with the severity of the PE. It reminds us, too, that nonspecific symptoms like dyspnée d'effort and orthopnoea may indicate a PE. JFW | T@lk 08:59, 30 September 2007 (UTC)

doi:10.1016/j.amjmed.2007.06.032 - more PIOPED II data; RV dysfunction without shock, recent MI, ventilation etc is not negatively prognostic (in contrast to some previous studies). JFW | T@lk 08:02, 30 January 2008 (UTC)

Wells score and Geneva test

Hello, in my last edit to this article, I linked Wells score and Geneva test, which currently lack articles as of this writing. I don't know if there is enough information about these to justify an article for each one. If you feel that these terms don't need articles of their own, feel free to remove the links in the PE article. --Kyoko 20:53, 4 November 2007 (UTC)

They only pertain to PE, so I would think that these scores should remain on this page unless there are serious space considerations. However, there is also a Wells' score for DVT... JFW | T@lk 22:32, 4 November 2007 (UTC)

Tachycardia

Is tachycardia a presenting sign of PE? —Preceding unsigned comment added by 147.8.77.248 (talk) 08:24, 4 December 2007 (UTC)

It can be. JFW | T@lk 11:06, 21 May 2008 (UTC)
was with me. --BozMo talk 16:11, 21 May 2008 (UTC)

I've had it!

After finding that T-wave inversion in III is non-specific and present in many normals, I was told by one of my senior colleagues that T3 in the McGinn-White pattern referred to the morphology of V3. That makes perfect sense, as T-inversions in V2-4 are quite common (in one study the commonest finding). Now I need to get my librarian to find a paper from 1935! JFW | T@lk 13:15, 13 May 2008 (UTC)

I've got the paper! Will read it closely over my lunch :-). JFW | T@lk 11:06, 21 May 2008 (UTC)

Thrombophilia

doi:10.1016/j.amjmed.2007.10.042 is a nice recent reference on the controversies around thrombophilia. JFW | T@lk 11:10, 21 May 2008 (UTC)

broken link?--BozMo talk 16:10, 21 May 2008 (UTC)
WFM. JFW | T@lk 12:13, 13 July 2008 (UTC)

Review

Konstantinides reviews PE - doi:10.1136/hrt.2005.071274 Actually mentions that the ESC is producing a guideline. JFW | T@lk 12:13, 13 July 2008 (UTC)

doi:10.1016/j.amjmed.2008.02.033 Review of "state of the art" and its problems. JFW | T@lk 20:23, 18 August 2008 (UTC)

PMID 15163775 - 2004 NEJM paper showing that CTEPH may occur after PE. PMID 18757870 is the new ESC guideline, not free for some bizarre reason. http://www.brit-thoracic.org.uk/ClinicalInformation/PulmonaryEmbolism/PulmonaryEmbolismGuidelines/tabid/138/Default.aspx BTS guideline] (UK) and ACCP 8th version guidelines (executive summary free only). JFW | T@lk 22:59, 10 November 2008 (UTC)

Argh, ESC guideline is 40 pages. JFW | T@lk 23:06, 10 November 2008 (UTC)

Should we include a list of Famous People who've had it/ died from it ?

Kaiser Wilhelm II? Invmog (talk) 02:41, 29 June 2009 (UTC)

warfarin, acenocoumarol, or phenprocoumon

I've had a pulmonary embolism while I was in the US and was put on warfarin. Because I had to have surgery after that, they took me of it and back on to heparin. Then I returned home to the Netherlands, where they put me on phenprocoumon. I asked my doctors why not warfarin and they informed me that acenocoumarol and phenprocoumon are the most commonly perscribed drugs in the Netherlands, and the later is specifically prescribed to patient who had a pulmonary embolism. According to them, warfarin was an older drug and that these two new drugs were better, without specifying why. My hematologist in the US informed me that a lot of recent research on anticoagulants was being done in the Netherlands, so I was wondering if acenocoumarol and phenprocoumon are intended to replace warfarin, because they are in some way superior, or if it is just a matter of local habits and availability which drugs gets prescribed?

Anyway, I've added the two drugs to the relevant section, but I have no reference. If you're a hematologist, would you mind finding a reference for me? Thanks!

    — SkyLined (talk) 20:04, 16 September 2009 (UTC)

To my knowledge, there is no superiority data for either sintrom nor marcoumar. Sintrom is shorter-acting than warfarin, hence easier to dose adjust. Marcoumar is longer-acting and hence allows for longer INR monitoring intervals. I agree that other vitamin K antagonists need to be mentioned for completeness, but most large studies have been done with warfarin. JFW | T@lk 20:07, 16 September 2009 (UTC)

We could also replace the list with the general description vitamin K antagonists?     — SkyLined (talk) 20:13, 16 September 2009 (UTC)

Warfarin is not registrated for use in the Netherlands (it is only used occasionally in hospitals). In the end, something like Dabigatran will probably replace them all. --WS (talk) 18:39, 18 September 2009 (UTC)
At ten times the cost of warfarin? It won't happen soon. Axl ¤ [Talk] 09:16, 19 September 2009 (UTC)

@Wouterstomp: Are you trying to say that we should not just mention Vitamin K antagonists, but use an even broader term? If so, what would you suggest?

    — SkyLined (talk) 20:02, 20 September 2009 (UTC)

I don't think we should generalise to vitamin K antagonists, because the majority of the English-speaking world uses warfarin (or Coumadin in the States, which is the same). All the same, we ought to mention the other VKAs for completeness. Oh and Axl, I think you'll find that when you deduct the cost of running anticoagulation clinics and checking everyone's INR all the time from the difference, dabigratran may actually become more cost-effective than warfarin! JFW | T@lk 21:50, 20 September 2009 (UTC)

Not so sure about this for long term users. My four INR tests a year cannot possibly cost the £1600 a year extra quoted for Dabigratan.. :) --BozMo talk 09:52, 22 September 2009 (UTC)
Why would we leave information out? If what you say is true, should the page not mention warfarin is most commonly used in most English speaking countries, but that other Vitamin K antagonists or anti-coagulants are used in some countries? Especially because I doubt this subject is covered in many other languages on Wikipedia at the moment, so people from all places around the world may be reading this page for lack of a native-language version.     — SkyLined (talk) 09:54, 21 September 2009 (UTC)

You're getting me wrong. I wasn't suggesting leaving anything out. Rather, we need to state that warfarin is most commonly used worldwide, as this is the case. However, because other VKAs are used in different countries these should be mentioned in passing. JFW | T@lk 22:53, 21 September 2009 (UTC)

MRI

I notice that there is no mention within the imaging section, for the use MRI in the PE diagnostic pathway. While the use of MRI certainly is not free of problems, there has been recent research which does seem to suggest a place for it (see here only one example [2]). MRI, as I am sure we are all aware, may have an especially important place in the PE investigative run-up during pregnancy (with the many issues that radiation exposure presents to the foetus and the inconclusiveness of Ultrasound. I am a little busy on an other article at the moment to make any large contribution to this but wondered what would be the thoughts of other editors to including some comment on MRI? Tuckerj1976 (talk) 23:01, 14 February 2010 (UTC)

I have never seen this used in practice, but the source seems good. JFW | T@lk 23:41, 14 February 2010 (UTC)
No it is far from common but has been used, especially during pregnancy, but again, this use has been very limited although considering the problems with gaining either a positive or negative confirmation with a V/Q perhaps this might be surprising (V/Q generates a far lower foetal dose than CT as I am sure you know) However, it is expected that MRI will now begin to enter the clinical setting as part of the standard work-up (during pregnancy at least - there are still issues with MRI compared to CT) [3] There was a very good review of the literature two years ago that covered all imaging pathways. I shall attempt to find a link to it once I either remember the authors or the title. In the meantime, there is also the following literature: [4], [5], [6] and [7]. Once I have finished with the other wiki project I shall attempt to give this more time, although MRI is not my major area of interest in Radiology Tuckerj1976 (talk) 00:26, 15 February 2010 (UTC)
If no one has any objections I shall add something shortly regarding MRI. I will be a little busy over the next few days at "work" but will work on something over the weekend hopefully. The involvement of someone working closely with MRI would be appreciated (and someone with better grammar than mine would be nice also). Tuckerj1976 (talk) 01:13, 18 February 2010 (UTC)

Historical reference

Virchow R. Die Verstopfung der Lungenarteire und ihre Folgen. Beitr Z exper Path 1846;2:227–380. JFW | T@lk 21:11, 14 November 2010 (UTC)

Merge discussion

Speedy close of merge proposal based on misunderstanding
The following discussion has been closed. Please do not modify it.

It is suggested that Cor pulmonale and Pulmonary embolism be merged as they appear to be discussing the exact same topic. Also, Pulmonary Heart Disease redirects to Pulmonary embolism, and Pulmonary heart disease redirects to Cor pulmonale, which seems counter-intuitive. Please indicate your Support or Oppose opinion below, and please include a rationale for your opinion. Please remember that this is a discussion, not a vote. ···日本穣? · 投稿 · Talk to Nihonjoe · Join WikiProject Japan! 16:55, 20 January 2011 (UTC)

This is a non-starter. See my justification for removing the merge discussion below. JFW | T@lk 18:49, 20 January 2011 (UTC)

Discussion

  • Oppose and speedy close. You were misled by the bad redirect at pulmonary heart disease. Pulmonary embolism is one of the numerous causes of cor pulmonale. Any lung disease that causes pulmonary hypertension can proceed to cor pulmonale. I have removed the merge notice as it is contradicted by plain fact. JFW | T@lk 18:49, 20 January 2011 (UTC)
Speedy closed by --BozMo talk 21:33, 20 January 2011 (UTC)

Saddle PE

The term "saddle PE" evokes fear amongst doctors, but it is not particularly awful compared to other main pulmonary artery PEs (doi:10.1111/j.1538-7836.2011.04189.x). Probably not includable as a non-MEDRS. JFW | T@lk 17:36, 2 May 2011 (UTC)

AF and PE?

I was asked by a medical student today whether pulmonary embolism may result from atrial thrombi as one would see in atrial fibrillation. Having looked around a bit, it seems that PMID 20531195 discusses this. Perhaps a little bit novel for inclusion, but certainly worth following up. JFW | T@lk 21:24, 20 June 2011 (UTC)

Apparently, this has been discussed in the literature since the 80s if not earlier. I'd say it warrants a mention. Fvasconcellos (t·c) 21:21, 21 June 2011 (UTC)

Addition about signs and symptoms

Arvindkanchan (talk · contribs) added the following:

Without a source for this very specific information I didn't want to leave it in the article, although this should be easily verifiable. I have left a message on the user's talkpage for attention. JFW | T@lk 10:38, 23 February 2012 (UTC)

The second quoted figure (when emboli obstruct more than 60%) looks too categorical. It has to depend a lot on the fitness of the individual. According to the CT I was over 60% (with both main pulmonary arteries heavily obstructed) and had none of those symptoms (although not conscious and perhaps lucky). --BozMo talk 10:02, 24 February 2012 (UTC)

Risk scores

Risk scores adequately predict low risk patients that may be suitable for outpatient management doi:10.1111/j.1538-7836.2012.04739.x.

The OTPE trial (doi:10.1016/S0140-6736(11)60824-6) demonstrates this well, but is a primary source still needing secondary source backup. JFW | T@lk 12:43, 17 April 2012 (UTC)

Anticoagulation in pregnancy

doi:10.1111/jth.12085 - dosing in pregnancy is not at all clear. JFW | T@lk 22:51, 4 December 2012 (UTC)

Thanks for the link. And I didn't know you could hyperlink doi's like that. Thanks. Biosthmors (talk) 23:31, 4 December 2012 (UTC)
I only learnt a while ago (from Wouterstomp (talk · contribs)) JFW | T@lk 21:40, 5 December 2012 (UTC)

scuba diving ?

Should scuba diving be included as a risk factor ? See WP http://en.wikipedia.org/wiki/Air_embolism and dive med literature.--— ⦿⨦⨀Tumadoireacht Talk/Stalk 01:01, 4 January 2013 (UTC)

Tricky. I personally believe that the concept "pulmonary embolism" without a modifier should be taken as being due to thrombus rather than any other kind of embolus. JFW | T@lk 14:46, 4 January 2013 (UTC)

Cleaned up Echo/Electrocardiography

There was talk of electrocardiography findings under the echocardiography findings. I have changed this. 94.193.2.50 (talk) 08:52, 16 May 2013 (UTC)

Thanks and welcome. Doc James (talk · contribs · email) (if I write on your page reply on mine) 09:50, 16 May 2013 (UTC)

Classification of symptoms into small, large and chronic P-embolus size

The symptoms need to be classified into the size of pulmonary embolus - small, large, chronic 129.180.161.173 (talk) 06:21, 31 May 2013 (UTC)

Nope. Show me the data that predicts the size of the embolus from the clinical history. Also, chronic PE is not covering in this article but in related content about CTEPH. JFW | T@lk 12:27, 2 June 2013 (UTC)

Saddle pulmonary embolism

LT910001 (talk · contribs) kindly merged Saddle embolus here. However, the content that was added is quite problematic. Firstly, the source (Mayo clinic) does not define "saddle embolus" at all. Secondly, there is substantial doubt about saddle emboli leading to death. Thirdly, the paragraph about saddle embolism ended up in the wrong section ("signs and symptoms").

I have therefore removed the paragraph, but added a clear mention of "saddle PE" in the imaging captions. Any further discussion of the concept should ideally be done in the "imaging" section.

The concept "saddle PE" strikes the fear into healthcare professionals because it is often found at postmortem. It has however become clear that if the proud owner of a saddle embolus is alive, their prognosis is not as ghastly as previously felt (doi:10.1111/j.1538-7836.2011.04189.x). JFW | T@lk 23:02, 31 August 2013 (UTC)

Thanks for your edits. Saddle PE is indeed something fearsome. LT90001 (talk) 23:09, 31 August 2013 (UTC)
Reassuringly, the AHA scientific statement from 2011 (doi:10.1161/CIR.0b013e318214914f) doesn't even mention the concept of "saddle PE", relying instead on clinical markers of severity. JFW | T@lk 23:22, 31 August 2013 (UTC)

Atrial fibrillation as risk factor

This has been suggested in the past, but there is an increasingly strong signal that risk of right-sided thromboembolism may be increased in atrial fibrillation. this paper is a primary research study, but I imagine there will soon be a secondary source to use for this association. JFW | T@lk 13:08, 21 October 2013 (UTC)

Embolic burden

The "embolic burden" can be assessed by the location of emboli on CT pulmonary angiography. It turns out that this has significant prognostic impact. The "obstruction index", however, performs poorly. This is a systematic review that we could include into the article (probably in the section discussing prognosis and risk stratification) - doi:10.1111/jth.12429. JFW | T@lk 13:47, 22 October 2013 (UTC)

Treatment review

JAMA doi:10.1001/jama.2014.65 JFW | T@lk 11:07, 20 February 2014 (UTC)

Thrombolysis

Meta-analysis in JAMA doi:10.1001/jama.2014.5990 JFW | T@lk 13:48, 15 September 2014 (UTC)

Stein & Dalen repeat the conclusion of many other sources - only thrombolyse in shock and no earlier. This is commentary so not directly for inclusion doi:10.1016/j.amjmed.2014.06.039 JFW | T@lk 21:50, 22 November 2014 (UTC)

Pregnancy

Another review about when to image pregnant women, and when not to. doi:10.1136/emermed-2014-203871 JFW | T@lk 16:54, 15 December 2014 (UTC)

ECS guideline

ECS and ERS have come out with guideline for PEs here. This should help fill the void of here (and the DVT article) where the newer oral anticoagulants are not even discussed (factor Xa inhibitors, etc). Yobol (talk) 03:00, 20 February 2015 (UTC)

ISTH/SSC recommendation

Incidentally found PE on cancer imaging is a big 'n' tricky problem. doi:10.1111/jth.12883 JFW | T@lk 13:53, 2 March 2015 (UTC)

MRA

Systematic review of MRI/MRA pulmonary arteries: ignore the grammar for now doi:10.1111/jth.13054 JFW | T@lk 11:38, 27 July 2015 (UTC)

Role of surgical pulmonary embolectomy

doi:10.1161/CIRCULATIONAHA.115.015916 JFW | T@lk 15:17, 24 September 2015 (UTC)

ACP best practice advice

doi:10.7326/M14-1772 - more support for PERC etc. JFW | T@lk 21:28, 7 October 2015 (UTC)

Peer Review for Wikipedia Elective for Bangabullet90

The lead is clearly organized by paragraph to address definition/cause of PE, clinical signs and symptoms, and diagnosis/treatment. It provides good framework for the remainder of the article. In the first paragraph, the sentence “The obstruction of the blood flow through the lungs…” is one I would consider revising for 2 reasons: 1) it is misplaced, 2) it expects your readers to know anatomy. This line should be in the paragraph of the lead addressing signs/sx and the association between the pulmonary artery and the right ventricle should be clarified as the average reader probably would not understand that. If your target audience is the medical community, then need for further explanation is not required. I think the number of links to other articles in the lead is appropriate. I would consider including the epidemiology section in the lead or moving it so that it occurs shortly after the lead.


The signs and symptoms section is heavy with medical jargon. Although you defined terms like dyspnea, tachypnea, and cyanosis in the first lines of this section, the repeated use of the words along with other words like hypoxyia, syncope, infarction, pleuritic, hemodynamic instability, hypotension, etc. make this section a difficult read for non-medical readers. (I am only saying this because this is the feedback from friends not in medicine).


I like the way the probability section is laid out. It is very easy to understand and interpret the scoring system by the way the information is presented.


Under the imaging section, I don’t know how useful it is to have the exact numbers for specificity and sensitivity. It complicates the read. Rather than stating those values, I think it would be better to interpret what a “specificity of 96%” means for readers.


The prevention section could use some fleshing out. I.e. what are the preventative medications? Are there specific risk factors that would make it more likely to start preventative meds? How many risk factors should be present to start preventative meds? Are drugs and stockings the only preventative measures?


Under “Anticoagulation” under the Treatment section, I would once again consider removing the statistics and just stating in simple English what the findings of the study were. Terminology used in research papers are not well understood by the general public, so it makes the article hard to follow.


Overall, I think this is a good article! At this point, it is definitely catering more to the medical community and is not the easiest read for a lay person. If this was your initial goal in reviewing the article, then you are on track. Otherwise, I would recommend that you send it to some of your non-medical school friends and ask them to read it to give you more direct feedback as well on how to make it a more generally readable article. — Preceding unsigned comment added by Pavikavarma (talk • contribs) 17:08, 16 November 2015 (UTC)

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