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Other Lessons Could Be Learned

      To the Editor:
      On the one hand, the report of pulmonary embolism attributable to initially misdiagnosed popliteal vein aneurysm was a salutary cautionary tale.
      • Krishan A.
      • Droste J.C.
      • Molloy K
      • et al.
      Popliteal vein aneurysm masquerading as a Baker's cyst leading to pulmonary embolism.
      On the other hand, however, it was a missed opportunity to exploit the principle that a test with modest diagnostic accuracy has the potential to generate a high positive predictive value for any given diagnosis when applied in the context of high pretest probability. Point-of-care transthoracic echocardiography (TTE) is one such test. If that test had been applied to the reported case, which was characterized by the association of chest pain, breathlessness, hypoxia, hypotension, and S1Q3T3, a combination with high pretest probability of pulmonary embolism, the identification, by TTE, of stigmata of pulmonary embolism such as right ventricular dilatation,
      • Bottinor W.
      • Turlington J.
      • Raza S
      • et al.
      Life-saving systemic thrombolysis.
      ,
      • Piggott Z.
      • Jelic T.
      Pulmonary embolism with cardiac arrest: a STEMI patient's unexpected course.
      right ventricular dilatation in a patient with S1Q3T3 sign,
      • Paterna S.
      • Fasullo S.
      • Di Pasquale P.
      • Fasullo S.
      An unusual presentation of massive pulmonary embolism mimicking septal acute myocardial infarction treated with tenecteplase.
      McConnell's sign,
      • Singh M
      • Guha D
      • Patterson B.
      Clot in transit: point-of-care ultrasound diagnosis of acute pulmonary embolism.
      and right heart thrombi
      • Singh M
      • Guha D
      • Patterson B.
      Clot in transit: point-of-care ultrasound diagnosis of acute pulmonary embolism.
      would have generated a sufficiently high positive predictive value to “clinch” the diagnosis of pulmonary embolism. By the same token, the identification of those stigmata
      • Bottinor W.
      • Turlington J.
      • Raza S
      • et al.
      Life-saving systemic thrombolysis.
      • Piggott Z.
      • Jelic T.
      Pulmonary embolism with cardiac arrest: a STEMI patient's unexpected course.
      • Paterna S.
      • Fasullo S.
      • Di Pasquale P.
      • Fasullo S.
      An unusual presentation of massive pulmonary embolism mimicking septal acute myocardial infarction treated with tenecteplase.
      • Singh M
      • Guha D
      • Patterson B.
      Clot in transit: point-of-care ultrasound diagnosis of acute pulmonary embolism.
      in patients with high pretest probability of pulmonary embolism proved to have high positive predictive value for pulmonary embolism when the “gold standard” for thromboembolism was subsequent documentation of pulmonary embolism by computed tomography pulmonary angiogram
      • Bottinor W.
      • Turlington J.
      • Raza S
      • et al.
      Life-saving systemic thrombolysis.
      • Piggott Z.
      • Jelic T.
      Pulmonary embolism with cardiac arrest: a STEMI patient's unexpected course.
      • Paterna S.
      • Fasullo S.
      • Di Pasquale P.
      • Fasullo S.
      An unusual presentation of massive pulmonary embolism mimicking septal acute myocardial infarction treated with tenecteplase.
      or identification of emboli in the right heart chambers.
      • Singh M
      • Guha D
      • Patterson B.
      Clot in transit: point-of-care ultrasound diagnosis of acute pulmonary embolism.
      One of the advantages of point-of-care TTE is that it “buys” time to undertake well-thought-out risk stratification strategies. Risk stratification, in turn, is the starting point for management strategies such as conventional anticoagulation vs thrombolysis or embolectomy.
      • Bĕlohlávek J
      • Dytrych V
      • Linhart A.
      Pulmonary embolism, part 1: epidemiology, risk factors and risk stratification, pathophysiology, clinical presentation, diagnosis and nonthrombotic pulmonary embolism.
      It was on the basis of the risk assessments made after point-of care TTE that each of the patients
      • Bottinor W.
      • Turlington J.
      • Raza S
      • et al.
      Life-saving systemic thrombolysis.
      • Piggott Z.
      • Jelic T.
      Pulmonary embolism with cardiac arrest: a STEMI patient's unexpected course.
      • Paterna S.
      • Fasullo S.
      • Di Pasquale P.
      • Fasullo S.
      An unusual presentation of massive pulmonary embolism mimicking septal acute myocardial infarction treated with tenecteplase.
      • Singh M
      • Guha D
      • Patterson B.
      Clot in transit: point-of-care ultrasound diagnosis of acute pulmonary embolism.
      received thrombolytic treatment without the prior benefit of computed tomography pulmonary angiogram.

      References

        • Krishan A.
        • Droste J.C.
        • Molloy K
        • et al.
        Popliteal vein aneurysm masquerading as a Baker's cyst leading to pulmonary embolism.
        Am J Med. 2021; 134: 1497-1500
        • Bottinor W.
        • Turlington J.
        • Raza S
        • et al.
        Life-saving systemic thrombolysis.
        Tex Heart Inst J. 2014; : 174-176
        • Piggott Z.
        • Jelic T.
        Pulmonary embolism with cardiac arrest: a STEMI patient's unexpected course.
        CJEM. 2018; 20: S31-S36
        • Paterna S.
        • Fasullo S.
        • Di Pasquale P.
        • Fasullo S.
        An unusual presentation of massive pulmonary embolism mimicking septal acute myocardial infarction treated with tenecteplase.
        J Thromb Thrombolysis. 2009; 27: 215-219
        • Singh M
        • Guha D
        • Patterson B.
        Clot in transit: point-of-care ultrasound diagnosis of acute pulmonary embolism.
        J Emerg Med. 2021; 60: 659-660
        • Bĕlohlávek J
        • Dytrych V
        • Linhart A.
        Pulmonary embolism, part 1: epidemiology, risk factors and risk stratification, pathophysiology, clinical presentation, diagnosis and nonthrombotic pulmonary embolism.
        Exp Clin Cardiol. 2013; 18: 129-138