the pesit trial

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Pulmonary Embolism in Syncope Italian Trial PESIT Trial Mohammed H. Elwan Associate Researcher, Emergency Medicine Academic Group, University of Leicester, UK Registrar in Emergency Medicine, University Hospitals of Leicester NHS Trust, UK Assistant Lecturer of Emergency Medicine, Alexandria University, Egypt UHL Journal Club – 7 th Feb 2017

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Page 1: The PESIT trial

Pulmonary Embolism in

Syncope Italian Trial PESIT Trial

Mohammed H. ElwanAssociate Researcher, Emergency Medicine Academic Group, University of Leicester, UK

Registrar in Emergency Medicine, University Hospitals of Leicester NHS Trust, UK

Assistant Lecturer of Emergency Medicine, Alexandria University, Egypt

UHL Journal Club – 7th Feb 2017

Page 2: The PESIT trial
Page 3: The PESIT trial

Today’s business• Background• Question• Methods• Strengths• Limitations• Conclusion

Page 4: The PESIT trial

Background What is syncope?- Transient LOC- Spontaneous resolutionCan PE cause syncope?Possibly,

Proximal obstruction ↓CO Syncope

Page 5: The PESIT trial

BackgroundWhat is the problem?

- PE is on the differential, but could it be paid little attention?

- Prevalence has not been rigorously studied, yet!

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QuestionWhat is the

prevalence of PEin patients hospitalized for

a first episode of syncope?

Page 7: The PESIT trial

MethodsDesign

• Prospective cross-sectional study

Setting• Multicentre - 11 Italian hospitals

Sampling• Consecutive patients

Page 8: The PESIT trial

MethodsInclusion

• > 18• Admitted after a first episode of syncope (LOC < 1min, complete resolution)

Exclusion• Obvious causes for syncope (seizures, head trauma, stroke)• Previous syncope• On anticoagulant therapy• Pregnancy

Sample size• estimated a sample size of 550 patients

Page 9: The PESIT trial

MethodsStudy

procedure

•Patients interviewed within 48h•CXR•ECG•ABG, routine bloods•D Dimer

Page 10: The PESIT trial

Diagnosing PEModified Well’s score

D Dimer

CT-PA/ VQ

scan

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PE criterionIntraluminal filling defect on CT-PA

Or a perfusion defect of at least 75% on VQ scan

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Thrombotic burdenIdentification of the most proximal location of the

embolus on the CT-PA or measurement of the severity of the perfusion defect on the VQ scan

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Results

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Results

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Results2584

ED patients

717Admitted

1867Discharged

from ED

Page 16: The PESIT trial

Results717

Admitted

560Included

157Excluded

Page 17: The PESIT trial

Results560

Included

330Low probability

+ negative D Dimer

PE Ruled out

230high

probability and/or positive

D Dimer

97PE

Confirmed

Page 18: The PESIT trial

Results

42.2%97/ 230

High probability patients

17.3%97/560

Entire cohort

560Included

330Low probability

+ negative D Dimer

PE Ruled out

230high

probability and/or positive

D Dimer

97PE

Confirmed

Page 19: The PESIT trial

Results

42.2%97/ 230

High probability patients

17.3%97/560

Entire cohort

25%52/205

undetermined origin of syncope

12.7%45/355

potential alternative explanation for

syncope

Page 20: The PESIT trial

ResultsThrombotic burden

63% Involved main pulmonary artery/ lobar artery

Page 21: The PESIT trial

Strengths- Multicentre- Consecutive patients- Validated guideline based work-up for PE

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Limitations- Did not include patients discharged from ED- The subjectivity of the diagnosis of syncope- Workup was standardised but not mandated- CT was done only in high likelihood/ high D Dimer cohort- No objective confirmation of DVT- Other syncope causes were left to the discretion of treating physician- Excluded patients with multiple syncope/ on anticoagulants

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Authors’ conclusion

Pulmonary embolism was identified in nearly

one of every six patients hospitalized for a first episode of syncope

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So,

What’s in this study for us?

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First,Let’s look at the numbers again

17.3%97/560 (study cohort)

97/2584 patients presenting to ED with syncope

Page 26: The PESIT trial

First,Let’s look at the numbers again

3.8%That is

One in 26

Page 27: The PESIT trial

Second,

Association ≠ causation

This study does not tell us whether identified PE is the cause of syncope or an incidental finding

(Not a question a cross-sectional study would answer anyway)

Page 28: The PESIT trial

Third,

Clinical significanceThis study does not tell us the significance of PE identification in

changing a “hard outcome”

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Bottom-line

Page 30: The PESIT trial

Thank you!