Episode 11 - Pulmonary Embolism: Part 3 - YEARS Algorithm

Network Five Emergency Medicine

Theme:
Pulmonary Embolism.

Participants:
Dr Bristi Roy (respiratory physician), Dr Vanessa Wong (respiratory advanced trainee), Dr Arwen Morath (emergency physician), Dr Pramod Chandru, Kit Rowe, and Caroline Tyers.

Discussion:
van der Pol, L., Tromeur, C., Bistervels, I., Ni Ainle, F., van Bemmel, T., & Bertoletti, L. et al. (2019). Pregnancy-Adapted YEARS Algorithm for Diagnosis of Suspected Pulmonary Embolism. New England Journal Of Medicine, 380(12), 1139-1149. https://doi.org/10.1056/nejmoa1813865.

Presenter:
Dr Vanessa Wong (respiratory advanced trainee at Westmead Hospital).

Summary:

• PE is a leading cause of maternal death in pregnant women.
• However, the radiation exposure to both mother and foetus involved in the diagnosis of PE remains a complex issue.
• This is a multi-centre prospective study that utilised the YEARS algorithm (published several years prior) and a D-dimer to predict PE in pregnant women presenting with suspected PE.
• The study was conducted over a 5-year period from October 2013 to May 2019.
• It looked at pregnant women over the age of 18 years that had been referred to ED or the obstetric ward with concerns for potential PE.
• The YEARS algorithm focuses on the 3 elements of the Well’s criteria considered to be the highest yield (being clinical signs of DVT, haemoptysis, and PE as the most likely diagnosis).
• As part of the algorithm, those patients with clinical signs of DVT underwent a doppler US and were commenced on anticoagulation (and presumed to have a PE) if this was positive for DVT.
• PE was excluded in those patients without any of the YEARS criteria and with a D-dimer less than 1.0.
• PE was also excluded in those who had 1-3 of the YEARS criteria and a D-dimer < 0.5, while those with 1-3 of the YEARS criteria and a D-dimer > 0.5 went on to have a CTPA to look for PE.
• The primary outcome was the cumulative incidence of symptomatic VTE on objective testing during a 3 month follow-up period.
• The secondary outcome was the proportion of patients in whom CTPA was not indicated to safely exclude PE.
• There were 510 pregnant women recruited into the study (46% of whom were in the third trimester of pregnancy) with 12 being excluded
• Of the 498 patients included, 4 had signs and symptoms of DVT with a positive doppler ultrasound.
• 20 patients of the remaining 494 were diagnosed with PE as part of the pathway.
• During follow-up, one popliteal DVT was diagnosed, and no patient had PE.
• CTPA was avoided in 195 patients (39%).

Take-Home Points:

• This provides a framework for assessing patients, particularly in the first and second trimesters of pregnancy (and may aid in safely excluding PE without CTPA for low-risk patients).
• However, in high-risk patients, pursuing a scan remains the most appropriate approach.

References:

• van der Hulle T, Cheung WY, Kooij S, et al. Simplified diagnostic management of suspected pulmonary embolism (the YEARS study): a prospective, multicentre, cohort study. Lancet 2017;390:289-297.

Credits:
This episode was produced by the ­­­­Emergency Medicine Training Network 5 with the assistance of Dr Kavita Varshney and, Deepa Dasgupta.

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See you next time,
Caroline, Kit, Pramod, Samoda, and Shreyas.

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