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Communications to the Editor |

Pulmonary Embolism—Treatment vs NontreatmentPulmonary Embolism—Treatment vs Nontreatment FREE TO VIEW

Dominick A. Rascona, MD; Barton C. Gumpert, MD, FCCP
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Affiliations: US Naval Medical Center Portsmouth, VA ,  Columbia University College of Physicians and Surgeons New York, NY



Chest. 1999;115(6):1755. doi:10.1378/chest.115.6.1755
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We appreciated the excellent article by Miller and colleagues describing objective measurements of right ventricular (RV) function in hemodynamically stable patients with acute pulmonary embolism (PE)[ March 1998].1 Although there was demonstrable decrement in RV function (ejection fraction, end-systolic area), their findings reassure us that routine echocardiography is not necessary in these patients, as early quantification did not help in determining which patients were at risk for clinical deterioration, including recurrent PE.

The authors’ claim, however, that an objective decrement in RV function persists after 6 weeks “despite treatment” may be open to debate. Abnormal RV function is reported as persisting with a fairly high degree of standard deviation compared with that of the authors’ normal controls. Although they initially evaluated 64 patients, 3 of these died and another 35 could not be reevaluated, leaving only 26 patients who could be followed sequentially. Perhaps most important is the potential confounding variable of nontreatment. Although only 2 of the 26 patients who were followed up were not treated with anticoagulation, and are reported as not differing significantly from those who were,1) we wonder why they were included in the analysis at all.

Vena caval interruption alone should not be considered as treatment for PE. This stopgap measure merely helps protect patients from further hemodynamic compromise when their thromboembolic disease cannot be treated, ie, with antithrombotic therapy, or when the extent of cardiopulmonary reserve is felt to be too marginal to risk another proximate embolic event. This topic has recently been discussed.2

Finally, it might be useful from such a descriptive study to know exactly what therapy the patients who suffered adverse events (four recurrent PEs, three deaths) were receiving (ie, anticoagulation, inferior vena caval filter, or both).

The views expressed are those of the authors and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government.

Correspondence to: Dominick A. Rascona, MD, Pulmonary and Critical Care Medicine, US Naval Medical Center, 620 John Paul Jones Circle, Portsmouth, VA 23708; e-mail: domrascona@prodigy.net

Miller, RL, Das, S, Anandarangam, T, et al (1998) Association between right ventricular function and perfusion abnormalities in hemodynamically stable patients with acute pulmonary embolism.Chest113,665-670. [PubMed] [CrossRef]
 
Decousus, H, Leizorovicz, A, Parent, F, et al A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis: Prevention du Risque d’Embolie Pulmonaire par Interruption Cave Study Group.N Engl J Med1998;338,409-415. [PubMed]
 

Pulmonary Embolism—Treatment vs Nontreatment

To the Editor:

I appreciate the comments of Drs. Rascona and Gumbert on our article assessing right ventricular function in hemodynamically stable patients with pulmonary embolism.1-1 I agree that our analysis suffers from the shortcoming of relatively high drop-out rate, making strong conclusions about the extent and prevalence of persistent right ventricular abnormalities during treatment difficult, despite the presence of statistical significance. The inclusion or exclusion of the two patients treated with inferior vena cava interruption alone did not affect the statistical analysis of our results. To answer the last question, all patients who suffered adverse events were receiving anticoagulation with heparin alone.

Correspondence to: Rachel L. Miller, MD, Department of Medicine, Columbia University College of Physicians and Surgeons, PH 8 Center, 630 W 168th St., New York, NY 10032; e-mail: rlm14@columbia.edu

References
Miller, RL, Das, S, Anandarangam, T, et al Association between right ventricular function and perfusion abnormalities in hemodynamically stable patients with acute pulmonary embolism.Chest1998;113,665-670. [PubMed] [CrossRef]
 

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References

Miller, RL, Das, S, Anandarangam, T, et al (1998) Association between right ventricular function and perfusion abnormalities in hemodynamically stable patients with acute pulmonary embolism.Chest113,665-670. [PubMed] [CrossRef]
 
Decousus, H, Leizorovicz, A, Parent, F, et al A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis: Prevention du Risque d’Embolie Pulmonaire par Interruption Cave Study Group.N Engl J Med1998;338,409-415. [PubMed]
 
Miller, RL, Das, S, Anandarangam, T, et al Association between right ventricular function and perfusion abnormalities in hemodynamically stable patients with acute pulmonary embolism.Chest1998;113,665-670. [PubMed] [CrossRef]
 
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