The diagnostic yield for computed tomography pulmonary angiography in patients with anticoagulation

doi:10.5847/wjem.j.1920-8642.2024.042

Abstract

Abstract:

BACKGROUND: Patients who present to the emergency department (ED) for suspected pulmonary embolism (PE) are often on active oral anticoagulation (AC). However, the diagnostic yield of computed tomography pulmonary angiography (CTPA) in screening for PE in patients who present on AC has not been well characterized. We aim to investigate the diagnostic yield of CTPA in diagnosing PE depending on AC status.

METHODS: We reviewed and analyzed the electronic medical records of patients who underwent CTPA for PE at a university hospital ED from June 1, 2019, to March 25, 2022. Primary outcome was the incidence of PE on CTPA depending on baseline AC status and indication for AC.

RESULTS: Of 2,846 patients, 242 were on AC for a history of venous thromboembolism (VTE), 210 were on AC for other indications, and 2,394 were not on AC. The incidence of PE on CTPA was significantly lower in patients on AC for other indications (5.7%) when compared to patients on AC for prior VTE (24.3%) and patients not on AC at presentation (9.8%) (P<0.001). In multivariable analysis among the whole cohort, AC was associated with a positive CTPA (odds ratio [OR] 0.26, 95% confidence interval [CI]: 0.15-0.45, P<0.001).

CONCLUSION: The incidence of PE among patients undergoing CTPA in the ED is lower in patients previously on AC for indications other than VTE when compared to those not on AC or those on AC for history of VTE. AC status and indication for AC may affect pre-test probability of a positive CTPA, and AC status therefore warrants consideration as part of future diagnostic algorithms among patients with suspected PE.

Key words: Pulmonary embolism, Computed tomography pulmonary angiography, Emergency department, Anticoagulation

Payush Chatta, Brian Diep, Jakrin Kewcharoen, Daniel Rossie, Cory Toomasian, Purvi Parwani, Dmitry Abramov. The diagnostic yield for computed tomography pulmonary angiography in patients with anticoagulation[J]. World Journal of Emergency Medicine, 2024, 15(4): 251-255.

Figures/Tables 3

Table 1.

Table 2.

Table 3.

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Variables	No AC at presentation (n=2,394)	AC at presentation for an indication of prior VTE (n=242)	AC at presentation for other indications (n=210)	P-value
Baseline characteristics
Age, years	58.5±17.1	58.7±16.9	68.4±14.1	<0.001
Male	1,236 (51.6%)	103 (42.5%)	124 (59.0%)	0.002
Hypertension	1,045 (43.6%)	125 (51.6%)	125 (59.5%)	<0.001
Diabetes mellitus	651 (27.2%)	78 (32.2%)	78 (37.1%)	0.003
Chronic obstructive pulmonary disease	234 (9.8%)	31 (12.8%)	40 (19.0%)	<0.001
Chronic kidney disease	367 (15.3%)	49 (20.2%)	58 (27.6%)	<0.001
History of heart failure	423 (17.7%)	79 (32.6%)	100 (47.6%)	<0.001
AC use
Warfarin	0	21 (8.6%)	55 (26.20%)	<0.01
Apixaban	0	148 (61.1%)	110 (52.30%)	0.19
Rivaroxaban	0	66 (27.2%)	43 (20.40%)	0.14
Dabigatran	0	7 (2.9%)	2 (1.0%)	0.06
Data at presentation
Systolic blood pressure, mmHg	130±26	127+23	125±23	0.019
Diastolic blood pressure, mmHg	77±16	77±16	76±15	0.490
Pulse rate, beats/min	98±21	96±22	96±25	0.240
Oximetry, %	96.1±4.3	96.3±4.4	96.0±3.6	0.650
NT-proBNP, pg/mL	4,675±12,300	6,528±14,490	7,267 ±12,348	0.017
Creatinine, mg/dL	1.36±1.71	1.29±1.39	1.54±1.42	2.400
D-dimer, μg/mL	4.68±6.22	4.25±5.31	3.48±5.31	0.490
Elevated troponin (patients with value >99^th percentile)	447 (30.5%)	49 (28.3%)	46 (29.10%)	0.810
INR (pts on warfarin)	-	1.72±0.95	2.04±1.75	0.03
Pulmonary embolism on CTPA	263 (9.8%)	59 (24.3%)	12 (5.7%)	<0.001

Variables	OR	95% CI	P-value
Baseline characteristics and comorbidities
Age	1.01	0.995 - 1.03	0.200
Male	1.22	0.77 - 1.91	0.400
Heart failure	0.56	0.32 - 0.98	0.043
Hypertension	1.02	0.62 - 1.70	0.940
Diabetes mellitus	0.92	0.55 - 1.54	0.750
Chronic obstructive pulmonary disease	1.05	0.54 - 2.04	0.950
Chronic kidney disease	0.78	0.42 - 1.48	0.450
Anticoagulation use	0.26	0.15 - 0.45	<0.001
History of VTE	98.7	51.6 - 188.8	<0.001
Admission vitals and laboratory values
Systolic blood pressure (per 10 mmHg)	0.84	0.72 - 0.96	0.014
Diastolic blood pressure (per 10 mmHg)	1.45	1.16 - 1.82	0.001
Oximetry (per 1%)	1.04	0.99 - 1.08	0.104
NT-proBNP (per 100 pg/mL)	1.003	1.000- 1.005	0.080
Creatinine	0.94	0.83 - 1.07	0.330
Elevated troponin	0.80	0.47 - 1.36	0.410

Variables	OR	95% CI	P-value
Baseline characteristics and comorbidities
Age	0.98	0.95 - 1.01	0.190
Male	1.47	0.64 - 3.38	0.360
Heart failure	0.43	0.17 - 1.08	0.070
Hypertension	0.89	0.36 - 2.21	0.810
Diabetes mellitus	1.96	0.79 - 4.87	0.150
Chronic obstructive pulmonary disease	1.26	0.38 - 4.23	0.710
Chronic kidney disease	1.09	0.34 - 3.50	0.880
History of VTE	3.19	1.21 - 8.39	0.020
Admission vitals and laboratory values
Systolic blood pressure (per 10 mmHg)	0.98	0.76 -1.28	0.890
Diastolic blood pressure (per 10 mmHg)	1.05	0.71 - 1.57	0.810
Oximetry (per 1%)	0.98	0.9 - 1.07	0.640
NT-proBNP (per 100 pg/mL)	1.01	1.00 - 1.012	0.003
Creatinine	0.96	0.60 - 1.55	0.870
Elevated troponin	0.11	0.02 - 0.54	0.010