DR.

COREY HEITZ (Orcid ID : 0000-0002-5040-3217)

DR. CHRISTOPHER BOND (Orcid ID : 0000-0002-1593-6659)
DR. JUSTIN MORGENSTERN (Orcid ID : 0000-0001-7969-1382)
Article
Accepted Article
Article type : Hot Off the Press

Hot off the Press: SGEM #276 – FOCUS on PE in Patients with Abnormal Vital Signs

Authors

Corey Heitz, MD
Lewis Gale Medical Center, Salem
Salem, VA
coreyheitzmd@gmail.com
540-632-2364

Justin Morgenstern, MD
Markham Stouffville Hospital
Markham, Ontario, Canada

Christopher Bond, MD
University of Calgary
Accepted

Calgary, Alberta, Canada

William K. Milne, MD
University of Western Ontario
Goderich, Ontario, Canada

Conflicts of Interest
No authors report conflicts of interest

Discussing: Daley et al. Increased Sensitivity of Focused Cardiac Ultrasound for Pulmonary
Embolism in Emergency Department Patients With Abnormal Vital Signs. Academic Emergency
Medicine, November 2019

Abstract
Pulmonary embolism (PE) is commonly suspected in patients presenting to the emergency
department, however the gold-standard diagnostic test of CTA of the pulmonary arteries cannot
always be performed rapidly. Focused cardiac ultrasound (FOCUS) has been studied previously as a
diagnostic test for PE, with mixed results. We review a study by Daley et al in which the authors
evaluated the diagnostic utility of FOCUS for PE in patients with unstable vital signs. We provide
critical analysis of the article, as well as summarize the social media discussion and feedback of a
podcast in which the authors discuss their work.

Background
Focused cardiac ultrasound (FOCUS) has been studied as an option for rapid, bedside diagnosis of
pulmonary embolism (PE) with disappointing results when applied to patients with stable vital
signs.(1) However, in patients with an elevated heart rate, signs of right ventricular dysfunction due to
PE are more prevalent.(2) Among signs of right ventricular dysfunction (RVD), tricuspid annular

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been through the copyediting, typesetting, pagination and proofreading process, which may
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doi: 10.1111/ACEM.13910
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 plane systolic excursion (TAPSE), which assesses for RVD using M-mode to measure movement of
the tricuspid annulus over the course of a contraction, has been shown to have a higher sensitivity for
PE than other signs, particularly in patients with unstable vital signs.(2,3) In this study, the authors
sought to investigate the test characteristics of FOCUS in patients with tachycardia and/or
Accepted Article
hypotension.

Article Summary
This was a prospective observational multi-center cohort study of patients undergoing FOCUS for
suspected PE. Patients were enrolled who were age 18 or older, presented with hypotension (SBP
<90mmHg) and/or tachycardia (HR >100) and were being evaluated by the treating physician with a
CTA assessing for PE. A convenience sample was enrolled when FOCUS-trained providers were
available in the department. FOCUS was used to evaluate for right ventricular dysfunction using
TAPSE, RV enlargement compared to the left ventricle, septal flattening, tricuspid regurgitation, or
McConnell’s Sign. Abnormal TAPSE was defined as <2.0cm. Any abnormal finding resulted in an
abnormal study. The primary outcomes were the sensitivity of FOCUS for PE in 1) patients with HR
>100bpm or SBP <90mmHg, and 2) patients with HR>110. Sensitivity was 92% in the first group,
with TAPSE being the most sensitive component of the exam. The sensitivity in those with a HR>110
was 100%, again with TAPSE as the most sensitive component.

Quality Assessment
This was a study with well-defined assessment criteria and outcomes, however the combination of
two primary outcomes was unusual. It is more typical to define one primary, and other secondary
outcomes. The selection of patients through a convenience same could introduce bias. Another source
of potential bias was blinding – some aspects of the treatment of individual patients may have clued
the investigators into the diagnosis. Training of the ultrasonographers was adequate, but there was a
fair amount of heterogeneity among the ultrasonographers. However, interrater reliability was very
good. The confidence intervals around the results are fairly wide, likely due to the small number of
patients enrolled in each group. A number of patients were excluded due to technical difficulties,
which provides a window into the real-world applicability of FOCUS for PE.

Key Results
143 patients who underwent CTA were screened. 136 subjects were ultimately enrolled in the study.
The mean age was in the mid-50’s, 59% were female, 23% had a previous VTE, 40% had cancer in
the previous 6 months and 15% had signs or symptoms of a DVT.

FOCUS had a sensitivity of 92% and specificity of 64% for PE

• Primary Outcomes:
• Sensitivity of FOCUS for PE in all patient with a HR ≥ 100 beats/min or sBP < 90 mm Hg was
92% (95%CI 78–98)
• Sensitivity of FOCUS for PE in patients with a HR ≥ 110 beats/min (n = 98) was 100% (95%
CI = 88% to 100%)

• Secondary Outcomes
• TAPSE sensitivity was 88% (95% CI 72-97) in all patients with unstable vital signs
• McConnell’s sign had 99% (95% CI 94-100) specificity in all patients with unstable vital signs

Authors’ Comments
Due to large confidence intervals surrounding the primary outcomes, FOCUS cannot be
recommended as a primary rule in or rule out tool for PE, even in unstable patients. There may be

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 some utility in ED settings where access to CTA is limited. However, in these settings, volumes of
patients may be low and skill maintenance may be difficult.

Comments from the blog

Accepted Article
Paul Olszynski
Great episode - with a great discussion on pragmatic research design and the nuances of diagnostic
and treatment threshold!
I think the reason the discussion tends to move beyond just diagnostic performance is because there's
a lot more to patient care than just getting the diagnosis right. Patients with hemodynamic
compromise from PE are sick - very sick. When working a busy shift (urban or rural), i think it helps
to know who needs our attention most (whether that's more frequent vitals, a team huddle to discuss
potential deterioration and action planning, or that longer conversation with that vulnerable patient
and their family) and any tool that helps identify the cause of illness, anticipate decline, or
prognosticate improves our ability to offer the best possible care. I think this study shows that FOCUS
can help in these aspects of care and ED management. Other research seems to support the idea that
the RV can also tell us a lot about how the patient might do - include predicting mortality (Tricuspid
annulus plane systolic excursion (TAPSE) has superior predictive value compared to right ventricular
to left ventricular ratio in normotensive patients with acute pulmonary embolism [PMID 27695491]
In EM, we get pulled in many directions. This type of information helps me determine who needs my
attention most, and who I can be less worried about. Having had conversations with the sick PE
patients – I have had the chance to impress onto them (and their loved ones) the seriousness of the
situation right there in the resuscitation room prior to further testing. I have had these same patients
cruise through with no trouble, I have seen some of them crash and then respond to lytic therapy, and
I have also seen some of them die. In every instance, being able to screen for sinister causes and/or the
heart's response to them (something that not too recently we could only guesstimate through indirect
measures like ECG, CXR, labs and invasive lines) through FOCUS (and POCUS more broadly) has
made a positive contribution to caring for the patient in front of me.
Jamesd85
Thanks for the insight Paul! I like your point about how we use ECG to screen for things like
PE (where the sens/spec LRs are much poorer than FOCUS). Just because a diagnostic test
doesn't have the necessary rule in/out stats (i.e. super sensitive), doens't mean it's not
potentially useful. I think it's a great thing to do (as you mention) in the initial workup of the
potentially sick patient - if some one has chest pain and tachycardia, I'm heading into the
room w/ my ultrasound cart to do the history/physical/ECHO all at the same time. Really can
help you triage people. Also can help you look for alternative dx (aortic root widening =
dissection, I typically look at lungs so it can often ID PNA or PTX). Importantly too for
people without a ton of experience - that's okay! just start practicing on those folks who come
in and who have had recent echos that you can compare your FOCUS results with.

Rajiv Thavanathon
I think it is an invaluable addition to Wells/YEARS + clin judgement in patients who are too sick for
CT where urgent decision needed re: lytics. Impt to know FP's and FN's of "RV dysfxn" and
limitations of RV:LV size, this goes double for arrested patients esp if long downtime.

Twitter Poll

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Accepted Article

Paper-in-a-pic from Kirsty Challen, @EMOttawa

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Accepted Article

Take-to-work Points
If access to CTA is limited, consider the use of FOCUS in unstable patients in whom you suspect PE.
Become comfortable with the several assessment measures, and understand that the most sensitive
finding is TAPSE <2.0cm and the most specific finding is McConnell’s sign. However, the diagnostic
characteristics of FOCUS are not adequate to rule in or rule out PE by itself.

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 References

1. Fields JM, Davis J, Girson L, Au A, Potts J, Morgan C, et al. Transthoracic

Echocardiography for Diagnosing Pulmonary Embolism: A Systematic Review
Accepted Article
and Meta- Analysis. J Am Soc Echocardiogr. 2017;30(7):714-723.e4.
2. Daley J, Grotberg J, Pare J, Medoro A, Liu R, Hall MK, et al. Emergency
physician performed tricuspid annular plane systolic excursion in the evaluation of
suspected pulmonary embolism. Am J Emerg Med. 2016;35(1):106-111.
3. Matthews JC, Mclaughlin V. Acute Right Ventricular Failure in the Setting of
Acute Pulmonary Embolism or Chronic Pulmonary Hypertension: A Detailed
Review of the Pathophysiology, Diagnosis, and Management. Curr Cardiol Rev.
2008;4(1):49-59.

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