Author
Catherine Le Gall
Bio: Catherine Le Gall is an academic researcher. The author has contributed to research in topics: Pulmonary embolism & Geneva score. The author has an hindex of 6, co-authored 8 publications receiving 957 citations.
Topics: Pulmonary embolism, Geneva score, Population, Medicine, Obstetrics
Papers
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TL;DR: The combination of pretest clinical probability assessment with age-adjusted D-dimer cutoff was associated with a larger number of patients in whom PE could be considered ruled out with a low likelihood of subsequent clinical venous thromboembolism.
Abstract: RESULTS Of the 3346 patients with suspected PE included, the prevalence of PE was 19%. Among the 2898 patients with a nonhigh or an unlikely clinical probability, 817 patients (28.2%) had a D-dimer level lower than 500 μg/L (95% CI, 26.6%-29.9%) and 337 patients (11.6%) had a D-dimer between 500 μg/L and their age-adjusted cutoff (95% CI, 10.5%-12.9%). The 3-month failure rate in patients with a D-dimer level higher than 500 μg/L but below the age-adjusted cutoff was 1 of 331 patients (0.3% [95% CI, 0.1%-1.7%]). Among the 766 patients 75 years or older, of whom 673 had a nonhigh clinical probability, using the age-adjusted cutoff instead of the 500 μg/L cutoff increased the proportion of patients in whom PE could be excluded on the basis of D-dimer from 43 of 673 patients (6.4% [95% CI, 4.8%-8.5%) to 200 of 673 patients (29.7% [95% CI, 26.4%-33.3%), without any additional false-negative findings. CONCLUSIONS AND RELEVANCE Compared with a fixed D-dimer cutoff of 500 μg/L, the combination of pretest clinical probability assessment with age-adjusted D-dimer cutoff was associated with a larger number of patients in whom PE could be considered ruled out with a low likelihood of subsequent clinical venous thromboembolism. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01134068
666 citations
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TL;DR: Whether physicians in emergency departments routinely used evidence-based diagnostic criteria for managing patients with suspected pulmonary embolism was assessed and whether the inappropriateness of the diagnostic criteria influenced the outcome of the patients was determined.
Abstract: Background: International guidelines include several strategies for diagnosing pulmonary embolism with confidence, but little is known about how these guidelines are implemented in routine practice. Objective: To evaluate the appropriateness of diagnostic management of suspected pulmonary embolism and the relationship between diagnostic criteria and outcome. Design: Prospective cohort study with a 3-month follow-up. Setting: 116 emergency departments in France and 1 in Belgium. Patients: 1529 consecutive outpatients with suspected pulmonary embolism. Measurements: Appropriateness of diagnostic criteria according to international guidelines; incidence of thromboembolic events during follow-up. Results: Diagnostic management was inappropriate in 662 (43%) patients: 36 of 429 (8%) patients with confirmed pulmonary embolism and 626 of 1100 (57%) patients in whom pulmonary embolism was ruled out. independent risk factors for inappropriate management were age older than 75 years (adjusted odds ratio, 2.27 [95% Cl, 1.48 to 3.47]), known heart failure (odds ratio, 1.53 [Cl, 1.11 to 2.12]), chronic lung disease (odds ratio, 1.39 [Cl, 1.00 to 1.94]), current or recent pregnancy (odds ratio, 5.92 [Cl, 1.81 to 19.30]), currently receiving anticoagulant treatment (odds ratio, 4.57 [Cl, 2.51 to 8.31]), and the lack of a written diagnostic algorithm and clinical probability scoring in the emergency department (odds ratio, 2.54 [Cl, 1.51 to 4.28]). Among patients who did not receive anticoagulant treatment, 44 had a thromboembolic event during follow-up: 5 of 418 (1.2%) patients who received appropriate management and 39 of 506 (7.7%) patients who received inappropriate management (absolute risk difference, 6.5 percentage points [Cl, 4.0 to 9.1 percentage points]; P < 0.001). Inappropriateness was independently associated with thromboembolism occurrence (adjusted odds ratio, 4.29 [Cl, 1.45 to 12.70]). Limitations: This was an observational study without evaluation of the risk for overdiagnosis. Conclusions: Diagnostic management that does not adhere to guidelines is frequent and harmful in patients with suspected pulmonary embolism. Several risk factors for inappropriateness constitute useful findings for subsequent interventions.
312 citations
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TL;DR: A diagnostic algorithm was evaluated that included an assessment of pretest clinical probability using the revised Geneva score, a highly sensitive D-dimer test, bilateral CUS, CTPA, and a V/Q scan if results of CTPA were inconclusive (Figure 1).
Abstract: Background Data on the optimal diagnostic management of pregnant women with suspected pulmonary embolism (PE) are limited, and guidelines provide inconsistent recommendations on use of diagnostic tests. Objective To prospectively validate a diagnostic strategy in pregnant women with suspected PE. Design Multicenter, multinational, prospective diagnostic management outcome study involving pretest clinical probability assessment, high-sensitivity D-dimer testing, bilateral lower limb compression ultrasonography (CUS), and computed tomography pulmonary angiography (CTPA). (ClinicalTrials.gov: NCT00740454). Setting 11 centers in France and Switzerland between August 2008 and July 2016. Patients Pregnant women with clinically suspected PE in emergency departments. Intervention Pulmonary embolism was excluded in patients with a low or intermediate pretest clinical probability and a negative D-dimer result. All others underwent lower limb CUS and, if results were negative, CTPA. A ventilation-perfusion (V/Q) scan was done if CTPA results were inconclusive. Pulmonary embolism was excluded if results of the diagnostic work-up were negative, and untreated pregnant women had clinical follow-up at 3 months. Measurements The primary outcome was the rate of adjudicated venous thromboembolic events during the 3-month follow-up. Results 441 women were assessed for eligibility, and 395 were included in the study. Among these, PE was diagnosed in 28 (7.1%) (proximal deep venous thrombosis found on ultrasonography [n = 7], positive CTPA result [n = 19], and high-probability V/Q scan [n = 2]) and excluded in 367 (clinical probability and negative D-dimer result [n = 46], negative CTPA result [n = 290], normal or low-probability V/Q scan [n = 17], and other reason [n = 14]). Twenty-two women received extended anticoagulation during follow-up, mainly for previous venous thromboembolic disease. The rate of symptomatic venous thromboembolic events was 0.0% (95% CI, 0.0% to 1.0%) among untreated women after exclusion of PE on the basis of negative results on the diagnostic work-up. Limitation There were several protocol deviations, reflecting the difficulty of performing studies in pregnant women with suspected PE. Conclusion A diagnostic strategy based on assessment of clinical probability, D-dimer measurement, CUS, and CTPA can safely rule out PE in pregnant women. Primary funding source Swiss National Foundation for Scientific Research, Groupe d'Etude de la Thrombose de Bretagne Occidentale, and International Society on Thrombosis and Haemostasis.
109 citations
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TL;DR: In European patients with low implicit clinical probability, PERC can exclude pulmonary embolism with a low percentage of false-negative results, which allow and justify an implementation study of the PERC rule in Europe.
57 citations
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TL;DR: The recently proposed YEARS algorithm was shown to safely exclude pulmonary embolism (PE) and reduce the use of computed tomography pulmonary angiography (CTPA) among pregnant women with suspected PE and this finding was externally validated.
29 citations
Cited by
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McMaster University1, American University of Beirut2, University of Alcalá3, University of Geneva4, Leiden University Medical Center5, Virginia Commonwealth University6, University of California, San Diego7, Ohio State University8, University of Utah9, UCLA Medical Center10, Ottawa Hospital Research Institute11, Uniformed Services University of the Health Sciences12
TL;DR: Recommendations on 12 topics that were in the 9th edition of these guidelines are updated, and 3 new topics are addressed.
3,934 citations
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TL;DR: Non-thrombotic PE does not represent a distinct clinical syndrome but may be due to a variety of embolic materials and result in a wide spectrum of clinical presentations, making the diagnosis difficult.
Abstract: Non-thrombotic PE does not represent a distinct clinical syndrome. It may be due to a variety of embolic materials and result in a wide spectrum of clinical presentations, making the diagnosis difficult. With the exception of severe air and fat embolism, the haemodynamic consequences of non-thrombotic emboli are usually mild. Treatment is mostly supportive but may differ according to the type of embolic material and clinical severity.
2,955 citations
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TL;DR: Guidelines summarize and evaluate all available evidence at the time of the writing process, on a particular issue with the aim of assisting health professionals in selecting the best management strategies for an individual patient, with a given condition, taking into account the impact on outcome.
Abstract: ACS
: acute coronary syndrome
AMPLIFY
: Apixaban for the Initial Management of Pulmonary Embolism and Deep-Vein Thrombosis as First-line Therapy
aPTT
: activated partial thromboplastin time
b.i.d.
: bis in diem (twice daily)
b.p.m.
: beats per minute
BNP
: brain natriuretic peptide
BP
: blood pressure
CI
: confidence interval
CO
: cardiac output
COPD
: chronic obstructive pulmonary disease
CPG
: Committee for Practice Guidelines
CRNM
: clinically relevant non-major
CT
: computed tomographic/tomogram
CTEPH
: chronic thromboembolic pulmonary hypertension
CUS
: compression venous ultrasonography
DSA
: digital subtraction angiography
DVT
: deep vein thrombosis
ELISA
: enzyme-linked immunosorbent assay
ESC
: European Society of Cardiology
H-FABP
: heart-type fatty acid-binding protein
HIT
: heparin-induced thrombocytopenia
HR
: hazard ratio
ICOPER
: International Cooperative Pulmonary Embolism Registry
ICRP
: International Commission on Radiological Protection
INR
: international normalized ratio
iPAH
: idiopathic pulmonary arterial hypertension
IVC
: inferior vena cava
LMWH
: low molecular weight heparin
LV
: left ventricle/left ventricular
MDCT
: multi-detector computed tomographic (angiography)
MRA
: magnetic resonance angiography
NGAL
: neutrophil gelatinase-associated lipocalin
NOAC(s)
: Non-vitamin K-dependent new oral anticoagulant(s)
NT-proBNP
: N-terminal pro-brain natriuretic peptide
o.d.
: omni die (every day)
OR
: odds ratio
PAH
: pulmonary arterial hypertension
PE
: pulmonary embolism
PEA
: pulmonary endarterectomy
PEITHO
: Pulmonary EmbolIsm THrOmbolysis trial
PESI
: pulmonary embolism severity index
PH
: pulmonary hypertension
PIOPED
: Prospective Investigation On Pulmonary Embolism Diagnosis
PVR
: pulmonary vascular resistance
RIETE
: Registro Informatizado de la Enfermedad Thromboembolica venosa
RR
: relative risk
rtPA
: recombinant tissue plasminogen activator
RV
: right ventricle/ventricular
SPECT
: single photon emission computed tomography
sPESI
: simplified pulmonary embolism severity index
TAPSE
: tricuspid annulus plane systolic excursion
Tc
: technetium
TOE
: transoesophageal echocardiography
TTR
: time in therapeutic range
TV
: tricuspid valve
UFH
: unfractionated heparin
V/Q scan
: ventilation–perfusion scintigraphy
VKA
: vitamin K antagonist(s)
VTE
: venous thromboembolism
Guidelines summarize and evaluate all available evidence at the time of the writing process, on a particular issue with the aim of assisting health professionals in selecting the best management strategies for an individual patient, with a given condition, taking into account the impact on outcome, as well as the risk-benefit-ratio of particular diagnostic or therapeutic means. Guidelines and recommendations should help the health professionals to make decisions in their daily practice. However, the final decisions concerning an individual patient must be made by the responsible health professional(s) in consultation with the patient and caregiver as appropriate.
A great number of Guidelines have …
2,113 citations
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University of Mainz1, Paris Descartes University2, University of Perugia3, Carlos III Health Institute4, Utrecht University5, Helsinki University Central Hospital6, Leiden University7, French Institute of Health and Medical Research8, Imperial College London9, University of Alcalá10, University Hospital of Lausanne11, Medical University of Vienna12, University of Göttingen13, Maastricht University14, University of Franche-Comté15, University College Dublin16, Medical University of Warsaw17, University of Geneva18
TL;DR: Guidelines summarize and evaluate available evidence with the aim of assisting health professionals in proposing the best management strategies for an individual patient with a given condition.
Abstract: Guidelines summarize and evaluate available evidence with the aim of assisting health professionals in proposing the best management strategies for an individual patient with a given condition. Guidelines and their recommendations should facilitate decision making of health professionals in their daily practice. However, the final decisions concerning an individual patient must be made by the responsible health professional(s) in consultation with the patient and caregiver as appropriate.
2,079 citations
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TL;DR: New ESCardio Guidelines for the Diagnosis and Management of Acute PulmonaryEmbolism developed in collaboration with EuroRespSoc are available.
Abstract: New @ESCardio Guidelines for the Diagnosis and Management of Acute #PulmonaryEmbolism developed in collaboration with @EuroRespSoc now available: #cardiotwitter @erspublicationshttp://bit.ly/2HnrJaj
1,334 citations