David H. Wesorick, MD; Vineet Chopra, MD, MSc
Disclosures: Dr. Chopra reports grants from the Agency for Healthcare Research and Quality. Dr. Wesorick has disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-1400.
The diagnosis of suspected pulmonary embolism (PE) is best approached by using an algorithm that includes the estimation of pretest probability, the selective use of D-dimer testing (in patients with low or moderate pretest probability), and the use of appropriate imaging tests (which can include lower-extremity compression ultrasonography, computed tomography (CT) pulmonary angiography, or ventilation–perfusion scanning). The authors provide a diagnostic algorithm incorporating these tests and strategies.
The use of pretest probability tools can help clinicians decide when imaging is necessary, but it can also be helpful in detecting false-positive imaging results. For example, the posttest probability of PE in a patient with low pretest probability and a positive CT pulmonary angiogram is only 30%. Positive scans in these patients should be reviewed with an imaging specialist.
Pretest probability tools have not been well-studied in hospitalized patients, and D-dimer testing is not useful in this population. Therefore, the authors recommend that the evaluation of hospitalized patients with suspected PE forgo the algorithmic approach and move directly to imaging.
Patients undergoing peripheral arterial revascularization have a very high 30-day readmission rate.
Although procedural complications account for the largest segment of these readmissions (28%), sepsis (8.3%), diabetes (7.5%), and congestive heart failure (4.4%) are also important causes of readmission.
Readmitted patients were more likely to have comorbid conditions, such as chronic limb ischemia, obesity, hypertension, congestive heart failure, diabetes, or renal disease.
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Wesorick DH, Chopra V. Annals for Hospitalists - 16 January 2018. Ann Intern Med. 2018;168:HO1. doi: 10.7326/AFHO201801160
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Published: Ann Intern Med. 2018;168(2):HO1.
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