In the JournalsPerspective

Routine transthoracic echocardiography not beneficial in acute PE

David M. Cohen

Hospital use of transthoracic echocardiography in patients with hemodynamically stable, acute pulmonary embolism was not associated with inpatient mortality, but its use was linked to increased costs and resource utilization, published data indicate.

David M. Cohen, MD, from Boston University School of Medicine, told Cardiology Today’s Intervention that he and his colleagues have noticed wide variability in the use of transthoracic echocardiography (TTE) for evaluation of PE.

“A common clinical scenario that we often encounter is a patient with newly diagnosed PE who is otherwise hemodynamically stable, who undergoes TTE seemingly as a routine test. The question is: Does this test (TTE), that is routinely performed by some clinicians but not others, change clinical decisions in a way that improves patient outcomes?” Cohen said.

TTE may show evidence of right ventricular strain in patients who appear hemodynamically stable, which often triggers multiple consultations among pulmonologists, cardiologists and interventional radiologists to determine whether thrombolytics should be used or whether the patient should be admitted to the ICU for closer monitoring, according to Cohen.

“However, societal guidelines do not currently recommend routine use of thrombolytics — systemic or catheter directed — in these patients with hemodynamically stable PE, even in the presence of right ventricular strain,” he told Cardiology Today’s Intervention. “In our experience, the consultations for these patients very seldom lead to significant changes in treatment, but may be a source of increased resource utilization through consultations and ICU admissions.”

Downstream effects of TTE

Cohen and colleagues conducted a retrospective study using claims data from 2008 to 2011 to examine the extent of practice variation for use of TTE for the evaluation of patients with hemodynamically stable PE and to assess associations between TTE practice, patient outcomes and resource use. The analysis included 64,037 patients from 36 U.S. hospitals.

Ranging from 0% to 89%, there was significant variation among hospitals in the rates of TTE use for hemodynamically stable, acute PE (median, 41.4%), according to the study results.

Rates of TTE use were not associated with significant differences in risk-adjusted mortality (OR = 0.88; 95% CI, 0.69-1.13) or use of thrombolytics (OR = 1.28; 95% CI, 0.84-1.96). However, at hospitals with the highest rates of TTE use, there were increased risks for ICU admission (OR = 1.57; 95% CI, 1.18-2.07), longer length of hospital stay (RR = 1.08; 95% CI, 1.03-1.15) and higher costs (RR = 1.15; 95% CI, 1.07-1.23).

Similar results were observed in analyses of patient-level exposure to TTE, although there were higher rates of thrombolysis (OR = 5.58; 95% CI, 4.4-7.09) and bleeding (OR = 1.37; 95% CI, 1.24-1.51) among patients who underwent TTE.

Of the patients included in the study, the mean age was 62 years, 54% were women and 68% were white. Of the hospitals included, 41% were in the South, 89.6% were urban and 62.9% were nonteaching hospitals.

According to Cohen, these results confirm what he and his colleagues have experienced in clinical practice. Specifically, he noted, TTE was obtained frequently in patients with hemodynamically stable PE, with wide variability between TTE rates at different hospitals.

“Further, TTE use was not associated with significant changes in mortality, but was associated with increased resource utilization, and in some analyses with increased use of thrombolytics,” he said. “Our findings support the most recent American College of Chest Physicians (ACCP) guidelines for management of PE, which recommend selective, rather than routine, use of TTE to risk-stratify patients with hemodynamically stable, acute PE.”

Looking ahead

Cohen highlighted that the study data are from 2008 to 2011, which precede the 2012 to 2016 ACCP guidelines. Those guidelines, he said, recommended for the first time selective, but not routine, use of TTE in patients with hemodynamically stable, acute PE.

“In future studies, we would like to see if practice patterns in the use of TTE have changed since the current TTE-specific guideline recommendations were first published in 2012,” Cohen told Cardiology Today’s Intervention.

He noted that “more studies are needed to better define what constitutes appropriate ‘selective’ use of TTE that will improve patient outcomes.

“Finally, we eagerly await the results of prospective trials evaluating long-term outcomes of catheter-directed lytic therapy for patients with hemodynamically stable, acute PE. These trials may affect future guidelines regarding appropriate use of TTE in this patient population.” – by Melissa Foster

Disclosures: The authors report no relevant financial disclosures.

Editor’s note: This article was updated on Jan. 30 with quotes from Dr. Cohen.

David M. Cohen

Hospital use of transthoracic echocardiography in patients with hemodynamically stable, acute pulmonary embolism was not associated with inpatient mortality, but its use was linked to increased costs and resource utilization, published data indicate.

David M. Cohen, MD, from Boston University School of Medicine, told Cardiology Today’s Intervention that he and his colleagues have noticed wide variability in the use of transthoracic echocardiography (TTE) for evaluation of PE.

“A common clinical scenario that we often encounter is a patient with newly diagnosed PE who is otherwise hemodynamically stable, who undergoes TTE seemingly as a routine test. The question is: Does this test (TTE), that is routinely performed by some clinicians but not others, change clinical decisions in a way that improves patient outcomes?” Cohen said.

TTE may show evidence of right ventricular strain in patients who appear hemodynamically stable, which often triggers multiple consultations among pulmonologists, cardiologists and interventional radiologists to determine whether thrombolytics should be used or whether the patient should be admitted to the ICU for closer monitoring, according to Cohen.

“However, societal guidelines do not currently recommend routine use of thrombolytics — systemic or catheter directed — in these patients with hemodynamically stable PE, even in the presence of right ventricular strain,” he told Cardiology Today’s Intervention. “In our experience, the consultations for these patients very seldom lead to significant changes in treatment, but may be a source of increased resource utilization through consultations and ICU admissions.”

Downstream effects of TTE

Cohen and colleagues conducted a retrospective study using claims data from 2008 to 2011 to examine the extent of practice variation for use of TTE for the evaluation of patients with hemodynamically stable PE and to assess associations between TTE practice, patient outcomes and resource use. The analysis included 64,037 patients from 36 U.S. hospitals.

Ranging from 0% to 89%, there was significant variation among hospitals in the rates of TTE use for hemodynamically stable, acute PE (median, 41.4%), according to the study results.

Rates of TTE use were not associated with significant differences in risk-adjusted mortality (OR = 0.88; 95% CI, 0.69-1.13) or use of thrombolytics (OR = 1.28; 95% CI, 0.84-1.96). However, at hospitals with the highest rates of TTE use, there were increased risks for ICU admission (OR = 1.57; 95% CI, 1.18-2.07), longer length of hospital stay (RR = 1.08; 95% CI, 1.03-1.15) and higher costs (RR = 1.15; 95% CI, 1.07-1.23).

Similar results were observed in analyses of patient-level exposure to TTE, although there were higher rates of thrombolysis (OR = 5.58; 95% CI, 4.4-7.09) and bleeding (OR = 1.37; 95% CI, 1.24-1.51) among patients who underwent TTE.

Of the patients included in the study, the mean age was 62 years, 54% were women and 68% were white. Of the hospitals included, 41% were in the South, 89.6% were urban and 62.9% were nonteaching hospitals.

According to Cohen, these results confirm what he and his colleagues have experienced in clinical practice. Specifically, he noted, TTE was obtained frequently in patients with hemodynamically stable PE, with wide variability between TTE rates at different hospitals.

“Further, TTE use was not associated with significant changes in mortality, but was associated with increased resource utilization, and in some analyses with increased use of thrombolytics,” he said. “Our findings support the most recent American College of Chest Physicians (ACCP) guidelines for management of PE, which recommend selective, rather than routine, use of TTE to risk-stratify patients with hemodynamically stable, acute PE.”

Looking ahead

Cohen highlighted that the study data are from 2008 to 2011, which precede the 2012 to 2016 ACCP guidelines. Those guidelines, he said, recommended for the first time selective, but not routine, use of TTE in patients with hemodynamically stable, acute PE.

“In future studies, we would like to see if practice patterns in the use of TTE have changed since the current TTE-specific guideline recommendations were first published in 2012,” Cohen told Cardiology Today’s Intervention.

He noted that “more studies are needed to better define what constitutes appropriate ‘selective’ use of TTE that will improve patient outcomes.

“Finally, we eagerly await the results of prospective trials evaluating long-term outcomes of catheter-directed lytic therapy for patients with hemodynamically stable, acute PE. These trials may affect future guidelines regarding appropriate use of TTE in this patient population.” – by Melissa Foster

Disclosures: The authors report no relevant financial disclosures.

Editor’s note: This article was updated on Jan. 30 with quotes from Dr. Cohen.

    Perspective
    M. Chadi Alraies

    M. Chadi Alraies

    In this study, the authors concluded that echocardiography did not change mortality in patients with hemodynamically stable, acute PE. In fact, they found that it increased costs, length of hospital stay, overutilization of thrombolytics and subsequent bleeding.

    The authors also found wide variation among hospitals in the use of echocardiography in this patient population. Interestingly, though, only about 40% of the patients who were admitted with hemodynamically stable, acute PE had an echocardiogram. Given the fact that in our daily practice, most patients admitted with PE undergo echocardiography, this percentage seemed relatively low to me.

    Nevertheless, there is also another important distinction to be made here. The study focused on patients with PE who were hemodynamically stable. The fact remains, however, that some patients with normal BP on admission may have other indicators of adverse events, such as elevations in brain natriuretic peptide (BNP) or troponin or evidence of right ventricular dilation on a CT scan. These patients with evidence of myocardial injury should undergo an echocardiogram so that therapy can be expedited or escalated during admission. Therefore, it is worth noting that even in a stable cohort of patients with PE, physicians should still be cognizant of and looking for other predictors of right ventricular failure.

    The study’s large size — including its cohort of more than 63,000 patients who were admitted to more than 360 hospitals in the United States — is a major strength that lends credibility to the findings. As noted by the authors, however, the study is not without limitations. The use of claims data, for instance, is a concern, as it can introduce misclassification bias.

    Overall, the most important clinical implication of this study is that these findings support the 2016 guidelines from the American College of Chest Physicians regarding the evaluation and management of patients with acute PE who are hemodynamically stable, with the results emphasizing that echocardiography should be reserved for select patients, such as those presenting with PE who have signs or symptoms of hemodynamic instability.

    • M. Chadi Alraies, MD
    • Interventional Cardiology Fellow Wayne State University, Detroit Medical Center

    Disclosures: Alraies reports no relevant financial disclosures.