Can ED physicians use TAPSE to rule out PE?

tapse ultrasound

Background

Pulmonary embolism (PE) often makes it on the differential of emergency department (ED) patients with any sort of cardiac or pulmonary complaint, and it can be a diagnostic challenge to know how far into the work up of PE is necessary for each patient. Any bedside tool that can increase or decrease the likelihood ratio for PE could be beneficial. Bedside echocardiography is one of the key tools in an ED physicians belt to narrow down differentials or potentially rule out certain diseases.

Research shows that 30 to 70% of emergency department patients with a PE will exhibit signs of right ventricular dysfunction (RVD), and a focused transthoracic cardiac ultrasound (FOCUS) is effective at detecting RVD (1). However, common measures of RVD, such as right heart enlargement, can be challenging to assess and often are dependent on the operator (2,3). A different measure, tricuspid annular plane systolic excursion (TAPSE), has been shown to accurately detect RVD while also providing prognostic information and is the least user dependent measure (4-9).

To date, there is little research on the utility of TAPSE in diagnosing PE, this study aimed to assess the diagnostic characteristics of TAPSE for PE and to optimize the measurement cutoff of TAPSE in diagnosing a PE.

 

Emergency physician performed tricuspid annular plane systolic excursion in the evaluation of suspected pulmonary embolism

 

Clinical Question

    • How accurate is TAPSE in diagnosing a PE?
    • What is the optimal measurement cutoff of TAPSE in diagnosing a PE ?
    • How good is the inter-rater reliability of TAPSE
    • How good are physicians at visually estimating TAPSE?

Methods & Study Design

• Design 

Prospective, observational convenience sample of FOCUS in ED patients undergoing evaluation for suspected PE from April 2015 to April 2016.

• Population 

Subjects were eligible if they were 18 years or older and undergoing computed tomographic angiography (CTA) for evaluation of possible PE in the ED. Prisoners, wards of the state, and non–English-speaking patients were excluded.

• Intervention 

Patients underwent a FOCUS in the ED either prior to undergoing CTA or the operator was blinded to the results if the FOCUS was done after the CTA. The operators were ultrasound trained emergency physicians, fellow,  or residents with one medical student participating who was trained in measuring TAPSE.

• Outcomes  

The primary outcome was both describing the diagnostic test characteristics of TAPSE in diagnosing PE and optimizing the measurement cutoff of TAPSE in diagnosing a PE. The secondary outcomes were assessing inter-rater reliability, quantitative visual estimate of TAPSE, and to describe the diagnostic test characteristics of other measures of RVD.

Results

The study found that TAPSE was 72% sensitive and 66% specific when the cutoff was 2.0 cm. When using the pre-established TAPSE cut off of 1.7, TAPSE was 56% sensitive and 79% specific.

They noted that in the sub-group of patients who were either tachycardic or hypotensive, TAPSE became 94% specific and the FOCUS was 100% specific.

Additionally, TAPSE had high inter-rater reliability, physicians were able to qualitatively assess TAPSE as normal or abnormal, and the test characteristics of TAPSE were much more sensitive and specific for a PE than other measures on the FOCUS.

Strength & Limitations

Strengths:

This study was well designed for the question it sought to answer and did a good job limiting bias by blinding the participants. They asked clinically relevant questions.

Limitations:

This study was limited in that it was a convenience sample of patients making it susceptible to selection bias. Additionally, the ultrasound operators in this study had extensive ultrasound training and TAPSE training, thus it may not be generalizable to the standard population of emergency physicians.

Authors Conclusion

"The optimal cutoff for diagnosis of PE using TAPSE was determined to be 2.0 cm. The diagnostic test characteristics of TAPSE for PE are comparable to other measures of RVD, although TAPSE appears to be somewhat more sensitive and less specific. The incorporation of TAPSE into the evaluation of the right heart may increase the accuracy and reliability of beside echocardiography for the detection of PE, although our data suggest that FOCUS is of limited utility in all patients presenting with concern for PE.

However, FOCUS and TAPSE appear to be highly sensitive for PE in patients with tachycardia or hypotension. Additionally, emergency physicians with advanced training in emergency ultrasound are capable of measuring TAPSE with precision comparable to that reported in the cardiology literature. Emergency physicians are able to accurately visually estimate TAPSE as either normal or abnormal, based on an a prior cutoff of 1.7 cm. As a more reliable measure of RVD, TAPSE may also help EPs to determine the severity and prognosis of a patient diagnosed as having a PE."

Our Conclusion

TAPSE is only a moderately sensitive and specific test in diagnosing a PE. However, TAPSE can be a useful tool in patients who are hemodynamically unstable with a suspected PE. In this case, the sensitivity of TAPSE in diagnosing a PE increases dramatically and in the setting of a hemodynamically unstable patient with a normal TAPSE, PE is unlikely the etiology. This can be beneficial if a patient is too unstable to go for a CTA, to help with diagnostic clarification and decision making.

The Bottom Line 

TAPSE is not sensitive or specific enough to rule in or rule out PE, but the sensitivity dramatically improves in hemodynamically unstable patients. TAPSE has high inter-rater reliability.

Authors

This post was written by Allie Frankel, MS4 at UCSD School of Medicine, Charles Murchison, MD and Amir Aminlari, MD. 

References

Daley J, Grotberg J, Pare J, Medoro A, Liu R, Hall MK, Taylor A, Moore CL. Emergency physician performed tricuspid annular plane systolic excursion in the evaluation of suspected pulmonary embolism. Am J Emerg Med. 2017 Jan;35(1):106-111. doi: 10.1016/j.ajem.2016.10.018. Epub 2016 Oct 11. PMID: 27793505.

 

    1. 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;4:49–59.

    2. Pruszczyk P, Goliszek S, Lichodziejewska B, Kostrubiec M, Kurnicka K, Dzikowska- Diduch O, et al. Prognostic value of echocardiography in normotensive patients with acute pulmonary embolism. JACC Cardiovasc Imaging 2014;7(6):553–60.

    3. Zanobetti M, Converti C, Conti A, Viviani G, Guerriniti E, Boni V, et al. Prognostic Value of Emergency Physician Performed Echcardiography in Patients with Acute Pulmonary Embolism. West J Emerg Med 2013;14(5):509–17.

    4. Kline JA, Steuerwald MT, Marchick MR, Hernandez-Nino J, Rose GA. Prospective evaluation of right ventricular function and functional status 6 months after acute submassive pulmonary embolism: frequency of persistent or subsequent elevation in estimated pulmonary artery pressure. Chest 2009;136(5):1202–10.

    5. Jackson RE, Rudoni RR, Hauser AM, Pascual RG, Hussey ME. Prospective evaluation of two-dimensional transthoracic echocardiography in emergency department pa- tients with suspected pulmonary embolism. Acad Emerg Med 2000;7(9):994–8.

    6. Rudoni RR, Jackson RE, Godfrey GW, Bonfiglio AX, Hussey ME, Hauser AM. Use of Two-Dimensional Echocardiography for the Diagnosis of Pulmonary Embolus. J Emerg Med 1998;16(1):5–8.

    7. Bova C, Greco F, Misuraca G, Serafini O, Crocco F, Greco A, et al. Diagnostic utility of echocardiography in patients with suspected pulmonary embolism. Am J Emerg Med 2003;21(3):180–3.

    8. Kopecna D, Briongos S, Castillo H, Moreno C, Recio M, Navas P, et al. Interobserver reliability of echocardiography for prognostication of normotensive patients with pulmonary embolism. Cardiovasc Ultrasound 2014;12:29–38.

    9. Taylor RA, Moore CL. Accuracy of emergency physician-performed limited echocar- diography for right ventricular strain. Am J Emerg Med 2014;32(4):371–4.