{"id":888,"date":"2017-09-25T04:19:37","date_gmt":"2017-09-25T04:19:37","guid":{"rendered":"http:\/\/emultrasound.sdsc.edu\/?p=888"},"modified":"2020-07-22T00:06:45","modified_gmt":"2020-07-22T00:06:45","slug":"rv-dilation","status":"publish","type":"post","link":"https:\/\/emultrasound.ucsd.edu\/index.php\/2017\/09\/25\/rv-dilation\/","title":{"rendered":"Right ventricular dilatation on bedside echocardiography performed by emergency physicians aids in the diagnosis of pulmonary embolism"},"content":{"rendered":"<div class=\"mp-row-fluid motopress-row mpce-dsbl-margin-left mpce-dsbl-margin-right\">\n<div class=\"motopress-clmn mp-span12  mpce-dsbl-margin-left mpce-dsbl-margin-right\">\n<div class=\"motopress-text-obj\">\n<h2 style=\"text-align: center;\">Background<\/h2>\n<p style=\"text-align: center;\">Pulmonary embolism (PE) is a disease entity with a high mortality rate, ranging from 2.5-33%. Frequently, its\u00a0diagnosis is delayed or frankly missed\u00a0and often it is only discovered during autopsy. Around 66% of deaths occur during the first hour of presentation and 75% of deaths during the initial hospitalization. The mechanism of morbidity\/mortality for PE is thought to be secondary to right ventricle (RV) outflow obstruction, leading to circulatory collapse. Delays in diagnosis have been linked to issues with imaging (wait times, schedules), contrast in the setting of renal impairment, and poor IV access.<\/p>\n<p style=\"text-align: center;\">In the emergency department, it is not only critical to identify patients with PE, but also to identify those who are\u00a0at risk for decompensation and poor outcomes. This can be accomplished by evaluating for signs of RV dysfunction which has\u00a0been associated with RV failure, hemodynamic collapse, and death. Previous studies have shown that right ventricular dysfunction has been found in 27-40% of normotensive patients with PE. Well studied markers of RV dysfunction include elevated biomarkers [1], specific ECG findings (RBBB, tachycardia, S1Q3T3, anterior TWI, ST elevation aVR, atrial fibrillation) [2], and RV dysfunction on echocardiography [3]. While biomarkers and ECG are readily available to emergency providers (EP), these are less specific for the diagnosis of PE and bedside echocardiography may prove to be more useful for evaluation of PE and RV dysfunction.<\/p>\n<p style=\"text-align: center;\"><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/24075286\" target=\"_blank\" rel=\"noopener noreferrer\">Right Ventricular Dilatation on Bedside Echocardiography Performed by Emergency Physicians Aids in the Diagnosis of Pulmonary Embolism<\/a><\/p>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"mp-row-fluid motopress-row mpce-dsbl-margin-left mpce-dsbl-margin-right\">\n<div class=\"motopress-clmn mp-span12  mpce-dsbl-margin-left mpce-dsbl-margin-right\">\n<div class=\"motopress-accordion-obj motopress-accordion motopress-accordion-dark\" data-atts=\"{&quot;active&quot;:&quot;false&quot;,&quot;collapsible&quot;:true,&quot;header&quot;:&quot;&gt; div &gt; h3&quot;,&quot;heightStyle&quot;:&quot;content&quot;}\">\n<div class=\"motopress-accordion-item\"><h3>Clinical Question<\/h3><div>\n<p style=\"text-align: center;\"><span class=\"s2\">Does evaluation for right ventricular dilation by emergency physicians using bedside echocardiography add diagnostic value in the evaluation for suspected pulmonary embolism?\u00a0<\/span><\/p>\n<\/div><\/div>\n<div class=\"motopress-accordion-item\"><h3>Methods &amp; Study Design <\/h3><div>\n<ul>\n<li><strong>Design<\/strong>\n<ul>\n<li>Prospective observational\u00a0study<\/li>\n<\/ul>\n<\/li>\n<li><span class=\"s2\"><b>Population<\/b><\/span>\n<ul>\n<li class=\"li1\"><span class=\"s2\">Using a \u201cconvenience sample\u201d population of patients who presented to the ED at Boston Medical Center from June 2009 \u2013 August 2011, with a moderate to high suspicion (pretest probability) of having a PE.<span class=\"Apple-converted-space\">\u00a0 <\/span>Wells score <\/span><span class=\"s3\">\u2265<\/span><span class=\"s2\">2, those receiving PE imaging (CT, angio, V\/Q scan), or those who came in with diagnosis of PE. <\/span><\/li>\n<\/ul>\n<\/li>\n<li><strong>Exclusion criteria\u00a0<\/strong>\n<ul>\n<li>Non-english speakers<\/li>\n<li>Prisoners<\/li>\n<\/ul>\n<\/li>\n<li><strong>Intervention<\/strong>\n<ul>\n<li class=\"li1\"><span class=\"s2\">Transthoracic echocardiography (blinded of confirmatory results) was performed by 4 ED docs, 1 with advanced training in cardiac sonography. \u00a0The other 3 had standard 1-month residency rotation in ultrasound and a minimum of 25 cardiac ultrasounds; plus, 10 hours hands-on and 10 hours image review with principal investigator.<\/span><\/li>\n<li class=\"li1\"><em>Data collection<\/em>\n<ul>\n<li class=\"li1\"><span class=\"s2\">3 views recorded: parasternal short &amp; long axis, and apical 4-chamber, with primary measurement being qualitative assessment of RV size vs. LV size. Normal ratio (0.6:1)<\/span>\n<ul>\n<li class=\"li1\"><span class=\"s2\">Dilation defined as &gt;1:1 RV:LV ratio<\/span><\/li>\n<li class=\"li1\"><span class=\"s2\">RV length and diameter or qualitative distension of RV apex adjacent to LV apex also assessed<\/span><\/li>\n<\/ul>\n<\/li>\n<li class=\"li1\"><span class=\"s2\">They also recorded: RV function (nl vs. hypokinetic), paradoxical septal motion, and presence of McConnell\u2019s sign.<\/span><\/li>\n<li class=\"li1\"><span class=\"s2\">All image reads were reviewed by the PI.<\/span><\/li>\n<li class=\"li1\"><span class=\"s2\">ED RAs then used chart review to compare findings to confirmatory imaging<\/span>\n<ul>\n<li class=\"li1\"><span class=\"s2\">PE was categorized as proximal vs distal<\/span><\/li>\n<li class=\"li1\"><span class=\"s2\">Disposition of patient was also documented\u00a0<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<li><strong>Outcomes<\/strong>\n<ul>\n<li class=\"li1\"><span class=\"s2\">Diagnostic characteristics<\/span>\n<ul>\n<li class=\"li1\"><span class=\"s2\">Sensitivity, specificity, PPV, NPV, positive and negative likelihood ratios<\/span><\/li>\n<\/ul>\n<\/li>\n<li class=\"li1\"><span class=\"s2\">Presence of advanced signs of RV dysfunction<\/span>\n<ul>\n<li class=\"li1\"><span class=\"s2\">Right ventricular hypokinesis [qualitatively assessed as normal or hypokinetic], paradoxical septal motion, and McConnell\u2019s sign<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/div><\/div>\n<div class=\"motopress-accordion-item\"><h3>Results<\/h3><div>\n<p><img data-recalc-dims=\"1\" loading=\"lazy\" decoding=\"async\" class=\"aligncenter size-full wp-image-890\" src=\"https:\/\/i0.wp.com\/emultrasound.sdsc.edu\/wp-content\/uploads\/2017\/09\/Screen-Shot-2017-09-24-at-9.16.39-PM.png?resize=525%2C253\" alt=\"\" width=\"525\" height=\"253\" \/><\/p>\n<ul>\n<li>\n<ul>\n<li><strong>Final analysis<\/strong>\n<ul>\n<li>146 patients included in study<\/li>\n<li>126 with moderate\u00a0pretest probability<\/li>\n<li>20 with high pretest probability<\/li>\n<li>126 with normal RV:LV ratio, 17 with increased RV:LV ratio<\/li>\n<li>30 had PE, of these 15 also had increased RV:LV ratio<\/li>\n<\/ul>\n<\/li>\n<li><strong>Presence of RV dilation test characteristics<\/strong>\n<ul>\n<li>Sensitivity 50% (95% CI 32% to 68%)<\/li>\n<li>Specificity 98% (95% CI 95% to 100%), a positive predictive value of 88%<\/li>\n<li>Positive Predictive Value 88% \u00a0negative predictive value of 88%<\/li>\n<li>Negative Predictive Value 88% (95% CI 83% to 94%).<\/li>\n<li>Positive Likelihood Ratio 29 (95% CI 6.1% to 64%)<\/li>\n<li>Negative Likelihood Ratio 0.51 (95% CI 0.4% to 0.7%)<\/li>\n<li>Good observer agreement 96%, independent 100%<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/div><\/div>\n<div class=\"motopress-accordion-item\"><h3>Strengths &amp; Limitations<\/h3><div>\n<ul>\n<li><strong>Strengths<\/strong>\n<ul>\n<li class=\"li1\"><span class=\"s2\">Good concordance of sens\/spec with prior study observations, although higher sensitivity<\/span><\/li>\n<li class=\"li1\"><span class=\"s2\">Good intra-observer agreement\/reliability<\/span><\/li>\n<\/ul>\n<\/li>\n<li><strong>Limitations<\/strong>\n<ul>\n<li class=\"li1\"><span class=\"s2\">Single location, young population (less chronic diseases leading to RV changes)<\/span><\/li>\n<li class=\"li1\"><span class=\"s2\">Operator skill may not generalize to other physicians, other EDs.<span class=\"Apple-converted-space\">\u00a0 <\/span>PI was very experienced sonographer.<\/span><\/li>\n<li class=\"li1\"><span class=\"s2\">Convenience sample leading to possible selection bias.<\/span><\/li>\n<li class=\"li1\"><span class=\"s2\">Secondary outcomes under-powered.<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/div><\/div>\n<div class=\"motopress-accordion-item\"><h3>Author's Conclusions <\/h3><div>\n<p style=\"text-align: center;\">The authors conclude that right ventricular dilatation on bedside echocardiography may help emergency physicians rule in pulmonary embolism more rapidly by raising a provider\u2019s index of suspicion before definitive testing. They also note that this evidence supports the\u00a0concept that patients with a moderate to high pretest probability for pulmonary embolism and a bedside echocardiography result showing right ventricular dilatation should be considered for anticoagulation before definitive testing.<\/p>\n<p style=\"text-align: center;\">Lastly, they also comment on severity of PE, noting that patients with\u00a0signs of advanced right ventricular dysfunction on bedside echocardiography (right ventricular dilatation with right ventricular hypokinesis, McConnell\u2019 s sign, or paradoxical septal motion), tends to occur in patients with a larger clot burden who are more likely to be admitted to an ICU setting or\u00a0have in hospital mortality (though this study was not powered appropriately for this analysis).<\/p>\n<\/div><\/div>\n<div class=\"motopress-accordion-item\"><h3>Our Conclusions<\/h3><div>\n<p style=\"text-align: center;\">\u00a0We agree with the author's conclusions of this study that EP performed bedside echocardiography is a useful adjunct in the evaluation of suspected PE, both in identification of PE as well as risk stratification. We know that delays in diagnosis\/treatment\u00a0can lead to worse outcomes, however with the ability of EPs to perform bedside echocardiography and identify right ventricular dilation, this may reduce the time to both of these endpoints. It also seems reasonable that in patients who are moderate to high risk for PE, whom have evidence\u00a0of right ventricular dilation on bedside echocardiography, \u00a0be empirically treated with anticoagulation prior to definitive imaging, with the caveat that they have no high bleed risk.<\/p>\n<\/div><\/div>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"mp-row-fluid motopress-row mpce-dsbl-margin-left mpce-dsbl-margin-right\">\n<div class=\"motopress-clmn mp-span12  mpce-prvt-449-595bfa801309a mpce-dsbl-margin-left mpce-dsbl-margin-right\">\n<div class=\"motopress-text-obj\">\n<h2 style=\"text-align: center;\">The Bottom Line<\/h2>\n<h3 style=\"text-align: center;\">Emergency physician performed\u00a0bedside echocardiography can be used reliably to increase provider's index of suspicion for PE in patients demonstrating RV dilation; however, given its poor sensitivity, it should not be used as a screening tool for PE.<\/h3>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"mp-row-fluid motopress-row mpce-dsbl-margin-left mpce-dsbl-margin-right\">\n<div class=\"motopress-clmn mp-span12  mpce-dsbl-margin-left mpce-dsbl-margin-right\">\n<div class=\"motopress-accordion-obj motopress-accordion motopress-accordion-dark\" data-atts=\"{&quot;active&quot;:&quot;false&quot;,&quot;collapsible&quot;:true,&quot;header&quot;:&quot;&gt; div &gt; h3&quot;,&quot;heightStyle&quot;:&quot;content&quot;}\">\n<div class=\"motopress-accordion-item\"><h3>Authors<\/h3><div>\n<p>This post was written by Hector Guerrero, MS4 at UCSD. It was reviewed by Michael Macias, MD, Ultrasound Fellow at UCSD.<\/p>\n<\/div><\/div>\n<div class=\"motopress-accordion-item\"><h3>References <\/h3><div>\n<ol>\n<li>\n<ol>\n<li>Weekes AJ, e. (2017). Diagnostic Accuracy of Right Ventricular Dysfunction Markers in Normotensive Emergency Department Patients With Acute Pulmonary Embolism. - PubMed - NCBI. Ncbi.nlm.nih.gov. Retrieved 25 September 2017, from https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/26973178<\/li>\n<li>Shopp, J., Stewart, L., Emmett, T., &amp; Kline, J. (2015). Findings From 12-lead Electrocardiography That Predict Circulatory Shock From Pulmonary Embolism: Systematic Review and Meta-analysis. Academic Emergency Medicine, 22(10), 1127-1137. doi:10.1111\/acem.12769<\/li>\n<li>Dudzinski DM, e. (2017). Assessment of Right Ventricular Strain by Computed Tomography Versus Echocardiography in Acute Pulmonary Embolism. - PubMed - NCBI . Ncbi.nlm.nih.gov. Retrieved 25 September 2017, from https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/27664798<\/li>\n<li>Dresden S, e. (2017). Right ventricular dilatation on bedside echocardiography performed by emergency physicians aids in the diagnosis of pulmonary embolism. - PubMed - NCBI . Ncbi.nlm.nih.gov. Retrieved 25 September 2017, from https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/24075286<\/li>\n<\/ol>\n<\/li>\n<\/ol>\n<\/div><\/div>\n<\/div>\n<\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"Background Pulmonary embolism (PE) is a disease entity with a high mortality rate, ranging from 2.5-33%. Frequently, its\u00a0diagnosis is delayed or frankly missed\u00a0and often it is only discovered during autopsy. Around 66% of deaths occur during the first hour of presentation and 75% of deaths during the initial hospitalization. The mechanism of morbidity\/mortality for PE &hellip; <p class=\"link-more\"><a href=\"https:\/\/emultrasound.ucsd.edu\/index.php\/2017\/09\/25\/rv-dilation\/\" class=\"more-link\">Continue reading<span class=\"screen-reader-text\"> \"Right ventricular dilatation on bedside echocardiography performed by emergency physicians aids in the diagnosis of pulmonary embolism\"<\/span><\/a><\/p>","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_eb_attr":"","_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[5],"tags":[7,11],"class_list":["post-888","post","type-post","status-publish","format-standard","hentry","category-journal-club","tag-echocardiography","tag-pulmonary-embolism"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.0 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Right ventricular dilatation on bedside echocardiography performed by emergency physicians aids in the diagnosis of pulmonary embolism - UCSD Ultrasound<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/emultrasound.ucsd.edu\/index.php\/2017\/09\/25\/rv-dilation\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Right ventricular dilatation on bedside echocardiography performed by emergency physicians aids in the diagnosis of pulmonary embolism - UCSD Ultrasound\" \/>\n<meta property=\"og:description\" content=\"Background Pulmonary embolism (PE) is a disease entity with a high mortality rate, ranging from 2.5-33%. 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Frequently, its\u00a0diagnosis is delayed or frankly missed\u00a0and often it is only discovered during autopsy. Around 66% of deaths occur during the first hour of presentation and 75% of deaths during the initial hospitalization. The mechanism of morbidity\/mortality for PE &hellip; Continue reading \"Right ventricular dilatation on bedside echocardiography performed by emergency physicians aids in the diagnosis of pulmonary embolism\"","og_url":"https:\/\/emultrasound.ucsd.edu\/index.php\/2017\/09\/25\/rv-dilation\/","og_site_name":"UCSD Ultrasound","article_published_time":"2017-09-25T04:19:37+00:00","article_modified_time":"2020-07-22T00:06:45+00:00","og_image":[{"url":"http:\/\/emultrasound.sdsc.edu\/wp-content\/uploads\/2017\/09\/Screen-Shot-2017-09-24-at-9.16.39-PM.png","type":"","width":"","height":""}],"author":"UCSD Ultrasound","twitter_card":"summary_large_image","twitter_creator":"@ucsdsono","twitter_site":"@ucsdsono","twitter_misc":{"Written by":"UCSD Ultrasound","Est. reading time":"6 minutes"},"schema":{"@context":"https:\/\/schema.org","@graph":[{"@type":"Article","@id":"https:\/\/emultrasound.ucsd.edu\/index.php\/2017\/09\/25\/rv-dilation\/#article","isPartOf":{"@id":"https:\/\/emultrasound.ucsd.edu\/index.php\/2017\/09\/25\/rv-dilation\/"},"author":{"name":"UCSD Ultrasound","@id":"https:\/\/emultrasound.ucsd.edu\/#\/schema\/person\/b29066b4104637bc43b8a1c79c2cda34"},"headline":"Right ventricular dilatation on bedside echocardiography performed by emergency physicians aids in the diagnosis of pulmonary embolism","datePublished":"2017-09-25T04:19:37+00:00","dateModified":"2020-07-22T00:06:45+00:00","mainEntityOfPage":{"@id":"https:\/\/emultrasound.ucsd.edu\/index.php\/2017\/09\/25\/rv-dilation\/"},"wordCount":1147,"commentCount":0,"publisher":{"@id":"https:\/\/emultrasound.ucsd.edu\/#organization"},"image":{"@id":"https:\/\/emultrasound.ucsd.edu\/index.php\/2017\/09\/25\/rv-dilation\/#primaryimage"},"thumbnailUrl":"http:\/\/emultrasound.sdsc.edu\/wp-content\/uploads\/2017\/09\/Screen-Shot-2017-09-24-at-9.16.39-PM.png","keywords":["Echocardiography","Pulmonary Embolism"],"articleSection":["Journal Club"],"inLanguage":"en-US","potentialAction":[{"@type":"CommentAction","name":"Comment","target":["https:\/\/emultrasound.ucsd.edu\/index.php\/2017\/09\/25\/rv-dilation\/#respond"]}]},{"@type":"WebPage","@id":"https:\/\/emultrasound.ucsd.edu\/index.php\/2017\/09\/25\/rv-dilation\/","url":"https:\/\/emultrasound.ucsd.edu\/index.php\/2017\/09\/25\/rv-dilation\/","name":"Right ventricular dilatation on bedside echocardiography performed by emergency physicians aids in the diagnosis of pulmonary embolism - 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