the pesit trial
TRANSCRIPT
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
Today’s business• Background• Question• Methods• Strengths• Limitations• Conclusion
Background What is syncope?- Transient LOC- Spontaneous resolutionCan PE cause syncope?Possibly,
Proximal obstruction ↓CO Syncope
BackgroundWhat is the problem?
- PE is on the differential, but could it be paid little attention?
- Prevalence has not been rigorously studied, yet!
QuestionWhat is the
prevalence of PEin patients hospitalized for
a first episode of syncope?
MethodsDesign
• Prospective cross-sectional study
Setting• Multicentre - 11 Italian hospitals
Sampling• Consecutive patients
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
MethodsStudy
procedure
•Patients interviewed within 48h•CXR•ECG•ABG, routine bloods•D Dimer
Diagnosing PEModified Well’s score
D Dimer
CT-PA/ VQ
scan
PE criterionIntraluminal filling defect on CT-PA
Or a perfusion defect of at least 75% on VQ scan
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
Results
Results
Results2584
ED patients
717Admitted
1867Discharged
from ED
Results717
Admitted
560Included
157Excluded
Results560
Included
330Low probability
+ negative D Dimer
PE Ruled out
230high
probability and/or positive
D Dimer
97PE
Confirmed
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
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
ResultsThrombotic burden
63% Involved main pulmonary artery/ lobar artery
Strengths- Multicentre- Consecutive patients- Validated guideline based work-up for PE
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
Authors’ conclusion
Pulmonary embolism was identified in nearly
one of every six patients hospitalized for a first episode of syncope
So,
What’s in this study for us?
First,Let’s look at the numbers again
17.3%97/560 (study cohort)
97/2584 patients presenting to ED with syncope
First,Let’s look at the numbers again
3.8%That is
One in 26
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)
Third,
Clinical significanceThis study does not tell us the significance of PE identification in
changing a “hard outcome”
Bottom-line
Thank you!