F1000ResearchF1000Research2046-1402F1000 Research LimitedLondon, UK10.12688/f1000research.121642.1Case ReportArticlesCase Report: The importance of initial assessment in acute pulmonary embolism
[version 1; peer review: 1 approved with reservations]
ArdianaMeityConceptualizationData CurationFormal AnalysisFunding AcquisitionResourcesSupervisionVisualizationWriting – Original Draft PreparationWriting – Review & Editinghttps://orcid.org/0000-0002-1706-6247a123HidayatDwi Fachrul OctafianConceptualizationData CurationFormal AnalysisVisualizationWriting – Original Draft PreparationWriting – Review & Editinghttps://orcid.org/0000-0003-2544-858412WardhaniLouisa Fadjri KusumaConceptualizationData CurationFormal AnalysisVisualizationWriting – Original Draft PreparationWriting – Review & Editinghttps://orcid.org/0000-0001-8955-437312DeviPutu Dwipa KrisnaConceptualizationData CurationFormal AnalysisVisualizationWriting – Original Draft PreparationWriting – Review & Editing12TiksnadiBadai BhataraConceptualizationFormal AnalysisWriting – Review & Editinghttps://orcid.org/0000-0002-0314-55774
Faculty of Medicine, Airlangga University, Surabaya, East Java, 60132, Indonesia
Department of Cardiology and Vascular Medicine, Dr. Soetomo Hospital, Surabaya, East Java, 60286, Indonesia
Department of Cardiology and Vascular Medicine, Bhayangkara H.S. Samsoeri Mertojoso Hospital, Surabaya, East Java, 60231, Indonesia
Department of Cardiology and Vascular Medicine, University of Padjadjaran, Bandung, West Java, 45363, Indonesiameityardiana@fk.unair.ac.id
Background: Pulmonary embolism (PE) remains the third most frequent cardiovascular disease worldwide and is associated with high mortality rates. We presented a case of PE with a history of tibial surgery and showed the role of Computed Tomography Pulmonary Angiography (CTPA) in early diagnosis and management of PE.
Case presentation: A 23-year-old man was referred to our hospital with sudden dyspnea followed by sharp chest pain, haemoptysis, pre-syncope, diaphoresis, and weaknesses. He had a history of tibial surgery and immobilization one month before admission. His vital sign was unstable, with blood pressure of 110/60 mmHg (supported by Norepinefrin 0.5 mcg/kg/minutes), heart rate of 120 beats/minute, respiratory rate of 24 times/minute, and oxygen saturation of 99% (oxygen mask 6 lpm). An electrocardiogram showed sinus tachycardia with McGinn-White sign. A chest X-ray showed Palla sign. An echocardiogram showed reduced right ventricular systolic function with McConneal sign. CTPA was performed due to the moderate-high risk PE with the presence of hyperattenuating and partial filling defect. Streptokinase was then administered, followed by adequate anticoagulation using rivaroxaban for three months. The clinical and CTPA evaluation showed a good result.
Conclusions: Initial assessment using PE’s scoring system will help clinicians determine the needs of CTPA. CTPA has a sensitivity of 53-100% and a specificity of 83-100% for the diagnosis of PE. This makes CTPA mandatory in high-risk PE, thus speeding up the initial treatment, which correlates with clinical outcomes.
Pulmonary embolismPEhigh-risk pulmonary embolismVTECase ReportThe author(s) declared that no grants were involved in supporting this work.Background
Pulmonary Embolism (PE), as a part of Venous Thromboembolism (VTE), remains the third most frequent cardiovascular disease worldwide.
1 An annual incidence rate for PE ranges from 39-115 per 100,000 populations. The incidence rate per year is 1.5 per 1000 persons.
2,3 PE is associated with more than 370,000 deaths in European countries, in which 34% died suddenly or within a few hours of the acute events.
3 PE commonly occurs as a fatal event with or without hemodynamic instability in the acute cardiac unit. The mortality rate of PE is around 50-58% in hemodynamic instability patients and 8-15% in hemodynamics stable patients.
2 As it is a life-threatening condition, rapid and specific diagnostic tools are needed.
1–3
Computed Tomography Pulmonary Angiography (CTPA) has been proposed as a standard imaging modality to diagnose PE. CTPA has the advantages of availability, excellent accuracy, strong validation in prospective management outcomes, low rates of inconclusive results, short acquisition time, and allowing more comprehensive assessment of the clot burden in Pulmonary Arteries (PAs). These make CTPA the suitable diagnostic tool in the Acute Cardiac Care Setting.
2,3 We presented a case of pulmonary embolism with a history of tibial surgery and showed the role of CTPA in early diagnosis and management of pulmonary embolism.
Case presentation
A 23-year-old Javanese man, working as a content editor, was referred to our emergency room (ER) with a suspected pulmonary embolism. His chief complaint was sudden shortness of breath one hour before hospital admission. The symptoms were accompanied by sharp chest pain in the lower right posterior area and blood coughing. He also had a history of pre-syncope, diaphoresis, and weaknesses for the past week. The medical history revealed right tibial surgery with plate implantation one-month prior to his admission. He injured himself during mountain climbing and suffered an open tibial fracture. He had been taking full bed rest ever since. Based on the clinical feature, we used PE’s risk assessment to better diagnose the involvement of PE. The Geneva score of 9 and Wells’ score of 7 showed a moderate-high risk for PE (
Tables 1 and
2). Thus CTPA was planned.
The Geneva score applied in this case.
DVT, Deep Vein Thrombosis; PE, Pulmonary Embolism.
Geneva score (revised)
Age > 65
No (0)
Yes (+1)
Previous DVT or PE
No (0)
Yes (+3)
Surgery or lower limb fracture in past month
No (0)
Yes (+2)
Active malignant condition
No (0)
Yes (+2)
Unilateral lower limb pain
No (0)
Yes (+3)
Hemoptysis
No (0)
Yes (+2)
Heart rate
<75 (0)
75-94 (+3)
≥ 95 (+5)
Pain on lower limb palpation and unilateral edema
No (0)
Yes (+4)
0-3 points indicate low probability
4-10 points indicate intermediate probability
≥11 points indicate high probability
The Wells’ score applied in this case.
DVT, Deep Vein Thrombosis; PE, Pulmonary Embolism.
Wells’ Score for PE
Clinical sign and symptoms of DVT
No (0)
Yes (+3)
PE is #1 diagnosis OR equally like
No (0)
Yes (+3)
Heart rate > 100
No (0)
Yes (+1.5)
Immobilization at least 3 days OR surgery in the previous 4 weeks
No (0)
Yes (+1.5)
Previous, objectively diagnosed PE or DVT
No (0)
Yes (+1.5)
Hemoptysis
No (0)
Yes (+1)
Malignancy with treatment within 6 months or palliative
No (0)
Yes (+1)
Low Risk < 2 points
Intermediate Risk 2-6 pts
High Risk >6 points
PE unlikely 0-4
PE likely > 4 points (pts)
Upon admission in the referrer hospital, his vital signs showed blood pressure 80/60 mmHg, heart rate 140 beats/minute, respiration rate 28 times/minute, and oxygen saturation of 90% (free air). He was alert but seemed weak and cyanotic. Adequate oxygenation support, fluid administration, and inotropes were administered to stabilize him before referred to our hospital. It took 12 hours from first medical contact until he came to our hospital.
The vital sign in our hospital showed unstable hemodynamics supported by Norepinefrin 0.5 mcg/kg/minutes with a blood pressure of 110/60 mmHg, heart rate 120 beats/minute, respiratory rate 24 times/minute, and oxygen saturation of 99% (oxygen mask 6 lpm). Physical examination showed loud P2, tachycardia, and cold-wet perfusion.
The electrocardiogram revealed sinus tachycardia with normal frontal and horizontal axis, S waves in the lead I, deep Q waves in lead III, and T inversion in the lead III (McGinn-White sign), as shown in
Figure 1(A).
Supportive evaluation including (A) electrocardiogram and (B) chest X-ray showing Palla sign.
We performed laboratory examination, which resulted in increased D-dimer (20.770 ng/mL) with both troponin (50 ng/mL) and creatinine serum (1.0 mg/dL) within normal limit. The chest X-ray (CXR) examination showed enlarged right descending pulmonary artery (Palla sign), as shown in
Figure 1(B).
Echocardiography examination at the previous hospital revealed decreased Right Ventricular (RV) function with preserved left ventricular function (
Figure 2A). There was an akinetic segment at the basal–mid-right ventricle, whereas other segments were normokinetic (McConnel Sign), as shown in
Video 1 and
Figure 2B. Upon arrival at our ER, a CT Angiography examination was performed. It showed an hyperattenuating and partial filling defect, which supported a typical pulmonary embolism finding (
Figure 3;
Video 2).
The echocardiogram examination showed (A) reduced right ventricular systolic function (TAPSE 1.5 cm) and (B) the presence of McConneal sign. An akinetic segment was at the basal–mid-right ventricle, whereas other segments were normokinetic (red arrow).
RV, Right Ventricle; RA, Right Atrium; LV, Left Ventricle; LA, Left Atrium.
The Computed Tomography Pulmonary Angiography (CTPA) findings supporting the acute pulmonary embolism (A) unenhanced CT-scan demonstrated subtle region of hyperattenuating (white arrow); (B) the presence of partial filling defect pulmonary artery in long-axis view (polo mint sign as shown by blue arrow) and longitudinal view (railway track sign as shown by orange arrow).
Based on CTPA findings, supported by clinical and other examinations, Pulmonary Embolism was assessed with Pulmonary Embolism Severity Index (PESI) Score of 83 points (Class II, low risk 1.7-3.5% 30-days mortality rate) (
Table 3). He then received thrombolytic therapy with intravenous streptokinase 250,000 IU loading dose for 30 minutes, followed by streptokinase 100,000 IU for 24 hours. Afterwards, the patient was given anticoagulation with rivaroxaban 15 mg twice a day for 21 days and other supportive therapy. His symptoms were improved with reduction of chest pain and shortness of breath after 14 days admission. Follow-up therapy was given at discharge with rivaroxaban 15 mg once a day for three months.
The Pulmonary Embolism Severity Index (PESI) score applied in this case.
BP, Blood Pressure.
PESI score
Age
23 years old
Sex
Female (0)
Male (+10)
History of cancer
No (0)
Yes (+30)
History of heart failure
No (0)
Yes (+10)
History of chronic lung disease
No (0)
Yes (+10)
Heart rate ≥ 110
No (0)
Yes (+20)
Systolic BP < 100 mmHg
No (0)
Yes (+30)
Respiratory rate ≥ 30
No (0)
Yes (+20)
Temperature < 36°C
No (0)
Yes (+20)
Altered mental status
No (0)
Yes (+60)
O
2 saturation < 90%
No (0)
Yes (+20)
Low risk (≤65 Class I; 66-85 Class II) Mortality 1.9%
Intermediate risk (86-105 Class III; 106-125 Class IV) Mortality 18.4%
High risk (>125 Class V) Mortality 25%
The patient was monitored in the outpatient clinic. The patient had no complaints with normal physical examination results. After three months of anticoagulation treatment, CTPA was evaluated to assess the treatment efficacy. No residual pulmonary embolism or infarction was found (
Video 3).
Discussion
Pulmonary embolism is associated with a high mortality rate in the acute phase. Most patients die within the first few hours of the events, so early diagnosis helps provide better outcomes.
3 However, clinical features and baseline findings often cannot unequivocally rule out PE, whereas follow-up examination (CTPA) is not cost-effective. This causes a follow-up examination to be carried out only in intermediate-high risk PE.
2,3
PE is suspected in patients with shortness of breath, sharp chest pain, pre-syncope or syncope, and haemoptysis. Syncope may occur as a feature of hemodynamic instability and RV dysfunction. Assessment of risk factors such as history of injury and surgery is also necessary to support the suspicion of PE since orthopaedic procedures have the highest incidence of developing a PE (0,7-30% chance). A tibial fracture is associated as a strong risk factor for PE (OR >10) with an incidence of 0.21%. These are related to positioning during surgery and immobility that contributes to an increase in venous stasis. The Electrocardiogram (ECG) and CXR are often nonspecific, but tachycardia is followed by S1Q3T3 pattern (McGinn-White sign; Prominent S wave in the lead I, Q wave in the lead III, and T inversion in the lead III) is a strong predictor of PE. These patterns appear in 15-25% PE. We found patients with clinical, ECG, and CXR supporting moderate-high risk PE with hemodynamic instability (Wells’ score 7 and Geneva score 9).
2–5
Most patients will not survive within the first hours of the event. The consequences of a false-positive or false-negative diagnosis can be rapidly fatal in terms of PE; therefore, a prompt diagnosis leads to a better treatment and outcome.
6 The use of scoring systems guides the need for additional modalities. CT examination has good sensitivity and specificity in diagnosing PE. A meta-analysis showed that CTPA has a sensitivity of 53-100% and specificity of 83%-100%.
7 Unfortunately, it is often not yet available in some regional hospitals. As in this case, the patient was then referred to our hospital on a supportive clinical basis. However, fast and accurate results through a CTPA examination can help diagnose patients and determine the next management step.
Following an acute embolic event, the patient is at risk for fatal circulatory collapse due to right-sided heart failure and subsequent embolism. Assessment of hemodynamics, RV failure, and increased Pulmonary Arteries (PA) pressure as part of acute pulmonary hypertension (PHT) needs to be done carefully. Early recognition of acute right ventricular failure is an important sign that requires immediate treatment. The presence of acute embolic obstruction that significantly affects the pulmonary circulation could increases pulmonary vascular resistance (PVR), resulting in acute PHT. The clinical impact of an embolism depends not only on the size of the embolus but also on its cardiopulmonary status. The RV compensates for the obstruction of RV outflow by increasing RV contraction. This resulted in increased myocardial oxygen demand and decreased RV efficiency. Pericardial constraint and RV dilatation lead to bowing the intraventricular septum into the Left Ventricle (LV), causing a decrease in LV preload. This is the underlying cause of circulatory collapse and cardiogenic shock. Echocardiography is a diagnostic modality that can monitor right ventricular strain or right ventricular failure. Echo provides visualization of RV clots, RV dilatation and hypokinesis, straightening, leftward bowing, paradoxical motion of the interventricular septum, decreased LV volume, tricuspid regurgitation, McConneal, and PA dilatation. The presence of RV hypertrophy (wall thickening > 5-6 mm) helps in differentiating acute, subacute, and chronic massive PE.
1,2,6
CTPA is mandatory in cases of high-risk PE. CTPA also has the ability to assess morphological abnormalities that indicate RV failure when it is found
1 RV dilatation (RV cavity size is larger than the LV) with or without contrast reflux into the hepatic veins
2; pulmonary embolism index more than 60%
3; Deviation of the intraventricular septum to the LV. CTPA has a sensitivity of 53-100% and a specificity of 83-100%. Acute PE conditions can be in the form of partial or total obstruction, which causes the appearance of
1 widening of the affected arteries due to impaired filling of the arterial lumen by total obstruction
2; The picture of a partial filling defect surrounded by contrast material due to a central partial occlusion, among which can be “polo mint sign” (long-axis view) and “railway track” (longitudinal view)
3; Peripheral intraluminal filling defect that forms acute angles to the arterial wall due to eccentric partial obstruction.
1,2,6
The echocardiogram findings of McConneal signs and decreased RV systolic function showed right heart failure. The CTPA findings of hyperattenuating and partial filling defect, as shown in
Figure 3, supported the involvement of PE as a cause of hemodynamic instability in this patient. Pulmonary embolism blocks pulmonary blood flow, resulting in right heart failure. Acute right heart failure due to lack of systemic output is the leading cause of death in high-risk PE. Initial therapy for pulmonary embolism focuses on restoring circulation through the pulmonary vessels and subsequently preventing the pulmonary embolism recurrence. Experimental studies indicate that aggressive volume expansion is not beneficial and worsens right ventricular function because of mechanical overstretch or reflex mechanisms that decrease contractility. However, light fluid administration (500 ml) can increase the cardiac index in PE patients, lower cardiac index, and normal blood pressure.
3,8
Thrombolytic therapy in acute PE aims to restore pulmonary perfusion more rapidly to reduce pulmonary arterial pressure and resistance, resulting in improved right ventricular function. The administration of fibrinolytic shows good outcome if performed within onset of 6-14 hours. As the patient came with hemodynamic instability, we administered streptokinase 250,000 IU intravenous loading dose within 2 hours, followed by 100,000 IU intravenously for 24 hours. Approximately >90% of patients respond to thrombolytics within 36 hours. Maximum profit will appear within 48 hours.
3
In patients with acute PE, anticoagulation is recommended to prevent death and symptom recurrence. The duration of anticoagulation is at least three months. The anticoagulation options lie between parenteral and oral therapies. Newer oral anticoagulants (NOACs) such as dabigatran, edoxaban, rivaroxaban, or apixaban could be an alternative therapy. The use of NOACs is non-inferior and safer than vitamin K-antagonists. Rivaroxaban can be started 1-2 days after administration of UFH, LMWH, or fondaparinux. Rivaroxaban is given 15 mg twice daily for three weeks, then 20 mg once for the following months.
3,9
Conclusions
The patient presented with moderate-high risk PE and was supported by clinical, ECG, Chest X-Ray, and echocardiography suggestive of PE. The use of PE’s risk assessment will help determine the needs of CTPA. CTPA has the advantages of availability, excellent accuracy, strong validation in prospective management outcomes, low rates of inconclusive results, short acquisition time, and allowing more comprehensive assessment of the clot burden in PAs. These make CTPA the suitable diagnostic tool in the Acute Cardiac Care Setting. Utilization of CTPA for the immediate diagnosis of pulmonary embolism patients helps determine the patient management accurately. Adequate therapy can reduce the risk of mortality and morbidity from pulmonary embolism.
Data availability
All data underlying the results are available as part of the article and no additional source data are required.
Consent
Written informed consent for publication of their clinical details and clinical images and videos was obtained from the patient.
Widgets
An echocardiogram showed reduced right ventricular (RV) systolic function and McConneal sign.
ReferencesWittramCMaherMMYooAJ:
CT angiography of pulmonary embolism: Diagnostic criteria and causes of misdiagnosis.Radiographics.2004;24(5):1219–1238.
1537160410.1148/rg.245045008GhayeBGhuysenABruyereP-J:
Can CTT PPullmonary Angiography Allow Assessment of Severity and Prognosis in Patients Presenting with Pulmonary Embolism? What the Radiologist Needs to Know.Radiographics.2006;26:23–39.
1641824010.1148/rg.261055062KonstantinidesSVMeyerGBuenoH:
2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European respiratory society (ERS).Eur. Heart J.2019; 00:1–61.ClementeV:
A case of pulmonary embolism after abdominal surgery.Ital. J. Emerg. Med.2017:1–4.KimHJWalcott-SappSLeggettK:
Detection of pulmonary embolism in the postoperative orthopedic patient using spiral CT scans.HSS J.2010;6(1):95–98.
1977441910.1007/s11420-009-9128-5WittramCKalraMKMaherMM:
Acute and chronic pulmonary emboli: Angiography-CT correlation.Am. J. Roentgenol.2006;186:S421–S429.
10.2214/AJR.04.1955RathbunSRaskobGWhitsettT:
Sensitivity and specificity of helical computed tomography in the diagnosis of pulmonary embolism: a systematic review.Ann. Intern. Med.2000;132:227–232.
1065160410.7326/0003-4819-132-3-200002010-00009SocietyTRC:
Pulmonary embolism, part I: Epidemiology, risk factors and risk stratification, pathophysiology, pulmonary embolism.2013;18:129–138.SakuragiTSakaoYFurukawaK:
Successful management of acute pulmonary embolism after surgery for lung cancer.Eur. J. Cardiothorac. Surg.2003;24(4):580–587.
1450007810.1016/S1010-7940(03)00392-0ArdianaMHidayatDFOWardhaniLFK:
Video 1. An echocardiogram showed reduced right ventricular (RV) systolic function and McConneal sign.f1000research.com. Media.2022.
10.6084/m9.figshare.20341371.v1ArdianaMHidayatDFOWardhaniLFK:
Video 2. The Computed Tomography Pulmonary Angiography (CTPA) examination performed in the emergency room.f1000research.com. Media.2022.
10.6084/m9.figshare.20342835.v1ArdianaMOctafian HidayatDFWardhaniLFK:
Video 3. The Computed Tomography Pulmonary Angiography (CTPA) evaluation performed in the outpatient clinic.f1000research.com. Media.2022.
10.6084/m9.figshare.20342874.v110.5256/f1000research.133529.r284679Reviewer response for version 1ValerioLuca1Refereehttps://orcid.org/0000-0003-4466-0724
Department of Cardiology, Johannes Gutenberg University Mainz, Mainz, Germany
Competing interests: No competing interests were disclosed.
This is a case report on a case of acute pulmonary embolism with a focus on the initial assessment, risk stratification, and risk-based management. It is very well written and presents a balanced mix of typical and atypical features. The typical features make the case interesting for the young physician, while the atypical ones will interest the experienced physician.
The typical features include the antecedent risk factor - orthopaedic surgery, the vital signs, and the symptoms. While it is uncommon for chest pain, hemoptysis, and pre-syncope to co-occur, these are all typical signs and it is interesting to find them in the same patient.
The atypical features include the relatively young age.
There is one major problem throughout the article that needs to be corrected. In pulmonary embolism, "high-risk probability of PE" and "high-risk PE" are two completely different things (note the words "probabality" and "of"). The first refers to the result of the assessment of the pre-test (or clinical) probability that a patient has PE at all before the gold standard test (CTPA or ventilation/perfusion scan) has been performed, and is used to decide whether to perform CTPA, because this may return false positive and may also unnecessarily expose patients to radiation. In contrast, "high-risk PE" refers to the assessment of risk of early (in-hospital or 30-days) death that occurs AFTER (or: at the same time as) a diagnosis has been made (using CTPA or ventilation/perfusion scan) based on a series of clinical, laboratory, and echocardiographic parameters, and is used to decide how to manage the patient (to sum up, low-risk patients can go home immediately, intermediate-risk patients may require only medium- or intensive-care monitoring, high-risk patients may require systemyc thrombolysis and intensive care monitoring). There is confusion between these two points in the Abstract and the Discussion. But to the PE clinician "high risk of PE" and "high-risk PE" mean, and should mean, two totally different things belonging to two separate stages of the management process. I detail below where the wording needs to be adapted to prevent this potentially dangerous misunderstanding.
There is also a very important missing point: an explicit statement of the risk stratification class. This must be made as clear as possible, because it guides the management of acute PE according to all current guidelines. In particular, it should be stated very explicitly that this patient was eligible for intravenous thrombolysis (which was indeed performed) because its risk class was high (high-risk PE) according to the European (ESC) guidelines, or, alternatively, massive according to the US guidelines. This point is of utmost importance, as this is the key element for the decision-making in acute PE.
Recommendations
ABSTRACT
1) even among clinicians working with patients with pulmonary embolism and devoting their career to clinical research in pulmonary embolism and, to the best of my experience, in most countries, it is very uncommon to refer to the S1Q3T3 pattern in the electrocardiogram as "McGinn-White Sign". It is much more common to refer to it as, indeed, "S1Q3T3 sign". I therefore suggest that the Authors write "S1Q3T3 pattern (McGinn-White sign)" instead of "McGinn-White sign"; that is, the eponymic form should be enclosed between parentheses after the more traditional one. For instance, the way the sign is described in the Case Presentation is entirely understandable. If the word limit for the Abstract is reached, just write "S1S3T3 pattern" without eponymic.
2) similarly, "Palla's sign" is relatively uncommon and I suggest to instead write "enlarged right pulmonary artery (Palla's sign)". Again, much better in the Case presentation. If the word limit for the Abstract is reached, just write "enlarged right pulmonary artery".
3) the exact spelling of the echocardiographic sign the Authors refer to is "McConnell sign" rather than "McConneal sign" (see for instance (Konstantinides SV.et.al., 2020 ref 2 ). Please correct.
4) This sentence cannot be correct: "CTPA was performed due to the moderate-high risk PE". The sentence suggests that, "because of" ("due to") a moderate-high risk PE, a CTPA was performed; that is, that it was known that the patient had a moderate-high risk PE before the CTPA was even performed. But it is impossible for a diagnosis of PE to be posed without imaging (CTPA or ventilation/perfusion scan). Therefore, the Authors must have meant either "due to the moderate-high risk pre-test risk of PE" or "A CTPA showed hyperattenuating and partial filling defect, confirming a moderate-high risk PE". In the latter case, "moderate-high" would refer to the PE risk stratification and would not be correct (in the European guidelines, the naming "intermediate-high" is used; in the US guidelines, the naming "submassive" is used). In the case presentation, a correct sentence is used: "(...) Wells' score of 7 showed a moderate-high risk for PE" (the "for" makes all of the difference!), revealing that the sentence in the Abstract fell in the first of the cases I described. Please correct accordingly.
5) "adequate anticoagulation" does not describe exactly what is adequate in this context. It would be more informative to write "therapeutic" anticoagulation (as opposed to prophylactic or sub-therapeutic).
KEYWORDS
6) I suggest that the keyword "Risk stratification" is added.
INTRODUCTION
7) For the sentence in the Introduction, a more recent and direct reference for the numbers of deaths in Europe is Barco S.et.al., 2020 ref 1 which should replace ref. 3. However, current reference 3 may be kept for the first sentence of the Discussion ("...helps provide better outcomes (3)").
8) It is not entirely correct to write "Computed Tomography Pulmonary Angiography (CTPA) has been proposed as a standard imaging modality to diagnose PE." because CTPA has not merely been proposed: it is in fact the current recommended standard, and has been for a long time now (over 20 years). This formulation may be misleading to younger doctors. I suggest the Authors write "Computed Tomography Pulmonary Angiography (CTPA) is the current standard imaging modality to diagnose PE."
CASE PRESENTATION
9) The sentence "we used PE’s risk assessment to better diagnose the involvement of PE." is linguistically very unclear (one does not "diagnose" an "involvement" in medicine, but only a disease; also, one does not diagnose "better" or "worse" - one either diagnoses or does not diagnoses). I think that the Authors should write clearly what they did: "We assessed the pre-test probability of PE based on the patient's clinical presentation". This sentence describes exactly the meaning and purpose of scores such as the Geneva score, the Wells score, or the Leiden score: establishing the probability a patient has a PE based solely on clinical and laboratory parameters and not on the diagnostic test CTPA (pre-test probability) in order to assess whether it is meaningful to perform a CTPA to diagnose PE.
10) "referring hospital" would be more common word usage than "referrer hospital".
11) please correct "before referred to our hospital" into either "before he was referred to our hospital" or "before referral to our hospital".
12) I believe it should be Norepinephrine rather than Norepinefrin - unless the latter is a commercial name for the active ingredient/active principle?
13) For the sake of conciseness, the Authors may write "Laboratory testing revealeed incraed D-dimer (...)" instead of "We performed laboratory examination, which resulted in (...)".
14) The numbers between brackets here are quite crowded: "(Class II, low risk 1.7-3.5% 30-days mortality rate)". It may be clearer if rewritten as "(Class II, low risk; 30-days mortality rate 1.7 to 3.5%)".
DISCUSSION
15) The sentences "However, clinical features and baseline findings often cannot unequivocally rule out PE, whereas follow-up examination (CTPA) is not cost-effective. This causes a follow-up examination to be carried out only in intermediate-high risk PE.2,3" does not seem to be correct. CTPA is not a "follow-up examination" in PE: it is the gold standard for diagnosis! In medicine, the wording "follow-up" is reserved for the long-term (chronic) monitoring of patients who have already a diagnosis and are currently stable; it is not used in acute/emergency medicine. The sentences may be misleading, as they suggest to the reader that CTPA is only performed in intermediate-high risk PE. This is absolutely not the case - even low-risk PE must have been diagnosed before it can be assessed as being low risk, and this must absolutely have occurred with either CTPA or ventilation/perfusion scan. I checked references 2 and 3 at the end of the second sentence, and I think there is a misunderstanding: CTPA should be carried out only in patients with a "intermediato to high pre-test probability of PE", NOT in patients with "intermediate-high risk PE" (the latter means that one already knows that the patients has PE because the CTPA has already been carried out, and that the patient has a high probability of DYING from PE, not of HAVING PE). I think rewriting the two sentences as follows would solve the issue: "However, clinical features and baseline findings often cannot unequivocally rule out PE, whereas CTPA, that can diagnose a PE, is not cost-effective in all patients, as it may lead to false positives and unnecessarily expose them to radiation. This causes the CTPA to be considered appropriate only in patients with a intermediate to high clinical risk of having a PE (2, 3).". In addition, please refer the reader, for maximum clarity, to a discussion of the latest guidelines where this point is examined explicitly, such as ref 1 (in addition to existing references 2 and 3). Note that the following paragraph is written in a perfectly correct way - the point is the SUSPICION of PE.
16) "Tachycardia is followed by S1Q3T3 pattern (...) is a strong predictor of PE": first, please remove the "is" (probably a type); second, it is not entirely true that this pattern is a strong predictor of PE; it is not very specific; to the best of my knowledge, less than 30% (I just noticed that you indeed write 25-30% in the next sentence, confirming what I thought). In biostatistics, usually, only positive predictive values above 90% justify the wordisng "strong prediction". I would rather write "strongly suggests PE".
17) "We found patients with (...)" supposedly refers to the patient described in this report; then, it would better be written as "In the patient we described in this Report, clinical signs, ECG and CXR findings all supported a moderate to high pre-test risk of PE (...)" (note that, once again, it would be wrong to write "moderate-high risk PE", because this wording would refer to the risk of early death).
18) "Most patients will not survive within the first hours of the event.": this is quite misleading, as the overall case fatality of PE does not go beyond 5%, and that hardly qualifies as "most patients". Only the subset of patients assessed as high-risk have a higher fatality. Please correct into "Patients with a high-risk PE may not survive beyond the first hours of the event".
19) Please correct "McConneal" into "McConnell sign".
20) In tthe sentence "Following an acute embolic event, the patient is at risk for fatal circulatory collapse due to right-sided heart failure and subsequent embolism.", please remove "subsequent embolism", because this is simply plainly wrong - the pulmonary embolism itself (the one already there) causes right-sided heart failure, and not a new, "subsequent" embolism following the right-sided heart failure. Please add a sentence detailing that therefore, once PE has been diagnosed, the risk of death from right-sided heart failure must be assessed based on several clinical and imaging parameters, so that the patient is assigned to a formal class that in turn determines; for the appropriate word use read and cite the 2019 ESC guidelines (Konstantinides SV.et.al., 2020 ref 2
) and/or, for a shorter practical example, Gallo A.et.al.,2019 ref 3
21) "CTPA is mandatory in cases of high-risk PE. ": once again, this is very misleading, because "high-risk PE" means "PE with high risk of death" and not "high pre-test probability of having PE". Please write "CTPA is mandatory in patients with a high pre-test probability of PE" or "CTPA is mandatory in patients with a high clinical probability of PE".
22) There is duplication of information and some kind of circularity in the DIscussion, because there are two separate paragraphs both on the diagnostic value of CTPA: the paragraph suarting with "most patients will not survive within the first hours (...)" and again the paragraph starting with "CTPA is manadatory in cases of high-risk PE". Note how they both report the same piece of information on the sensitivity and specificity of CTPA! Please merge the two paragraphs into a single paragraph that should precede the paragraph on the death risk stratification (which is the one starting with "Following an acute embolic event"). This is the most obvious and logical order: first, discuss the problem of diagnosis (pre-test probability to decide whether to perform CTPA); then, discuss the problem of risk of death/prognosis assessment.
23) The two sentences "Pulmonary embolism blocks pulmonary blood flow, resulting in right heart failure. Acute right heart failure due to lack of systemic output is the leading cause of death in high-risk PE." repeats for the second or third time what has already been said. This paragraph should re-focus on the current case and discuss treatment. Please remove the two sentences.
CONCLUSIONS
24) Once again, correct "moderate-high risk PE and was supported by clinical (...)" into "moderate to high pre-test probability of PE as suppored by (...)".
25) Correct "The use of PE’s risk assessment will help determine the needs of CTPA" into "The assessment of clinical (pre-test) probability of PE helps to decide on the need of CTPA".
26) Correct "in the Acute Cardiac Care Setting" into the more general and appropriate "in case of suspicion of PE in the acute setting".
27) Correct "Utilization of CTPA for the immediate diagnosis of pulmonary embolism patients helps determine the patient management accurately. Adequate therapy can reduce the risk of mortality and morbidity from pulmonary embolism." into "If a PE is diagnosed, CTPA also supports the subsequent assessment of the risk of early death from PE, guiding the choice of adequate therapy and ultimately reducing the risk of mortality and morbidity from PE".
Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?
Yes
Is the case presented with sufficient detail to be useful for other practitioners?
Partly
Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?
No
Is the background of the case’s history and progression described in sufficient detail?
Partly
Reviewer Expertise:
Clinical management and epidemiology of pulmonary embolism in particular and venous thromboembolism in general.
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
References:
Trends in mortality related to pulmonary embolism in the European Region, 2000-15: analysis of vital registration data from the WHO Mortality Database.Lancet Respir Med.2020;8(3) :
10.1016/S2213-2600(19)30354-6277-2873161571910.1016/S2213-2600(19)30354-6:
2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS).Eur Heart J.2020;41(4) :
10.1093/eurheartj/ehz405543-6033150442910.1093/eurheartj/ehz405:
The 2019 European guidelines on pulmonary embolism illustrated with the aid of an exemplary case report.Eur Heart J Case Rep.2021;5(2) :
10.1093/ehjcr/ytaa542ytaa5423359861810.1093/ehjcr/ytaa542