Transthoracic Echocardiography for Diagnosing Pulmonary Embolism: A Systematic Review and Meta-Analysis

• Published in: Journal of the American Society of Echocardiography Vol. 30; no. 7; pp. 714 - 723.e4
• Main Authors: Fields, J. Matthew, Davis, Joshua, Girson, Lily, Au, Arthur, Potts, Jacqueline, Morgan, Charity J., Vetter, Imelda, Riesenberg, Lee Ann
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.07.2017
• Subjects: Cardiovascular; Critical care; Diagnosis, Differential; Echocardiography - methods; Humans; Pulmonary embolism; Pulmonary Embolism - diagnostic imaging; Ultrasonography; Ultrasound; RV; HSROC; VTE; FOCUS; RVSP; Critical care; MeSH; PRISMA; LV; RVEDD; TAPSE; Pulmonary embolism; CT; PE; PAH; RH; Ultrasonography; V/Q; Ultrasound; TR; ED; RHT; Right heart thrombus; Right ventricular, ventricle; Right ventricular end diastolic diameter; Tricuspid regurgitation; Right ventricular systolic pressure; Emergency department; Computed tomography; Right heart; Pulmonary arterial hypertension; Preferred Reporting in Systematic Reviews and Meta Analyses; Venous thromboembolism; Ventilation/perfusion; Focused cardiac ultrasound; Hierarchical summary receiver operator curve; Tricuspid annular plane systolic excursion; Left ventricular, ventricle; Medical subject headings
• ISSN: 0894-7317; 1097-6795; 1097-6795
• DOI: 10.1016/j.echo.2017.03.004

Pulmonary embolism (PE) is a common diagnosis with significant mortality if not appropriately treated. The use of transthoracic echocardiography in patients with PE is common; however, its diagnostic capabilities in this use are unclear. With the increased use of ultrasonography in medical settings, it is important to understand the strengths and limitations of echocardiography for the diagnosis of PE. We conducted a systematic review of PubMed, CINAHL, and EMBASE through 2016 for articles assessing the diagnostic accuracy of transthoracic echocardiography for PE. Two authors independently abstracted relevant data from the studies. We assessed quality using the QUADAS-2 tool for diagnostic studies. Undefined “right heart strain” was the most common sign used, and it had a sensitivity of 53% (95% CI, 45%–61%) and a specificity of 83% (95% CI, 74%–90%). Eleven other distinct signs were identified: ventricle size ratio, abnormal septal motion, tricuspid regurgitation, 60/60 sign, McConnell’s sign, right heart thrombus, right ventricle hypokinesis, pulmonary hypertension, right ventricular end-diastolic diameter, tricuspid annular plane systolic excursion, and right ventricular systolic pressure. Studies show a consistently high specificity and low sensitivity for echocardiography in the diagnosis of PE, making it potentially adequate as a rule-in test at the bedside in critical care settings such as the emergency department and intensive care unit for patients with a suspicion of PE, especially those unable to get other confirmatory studies. Future research may continue to clarify the role of bedside echocardiography in conjunction with other tests and imaging in the overall management of PE. •The current article represents one of the most thorough meta-analyses of transthoracic echocardiography for pulmonary embolism to date and confirms a moderate sensitivity and high specificity across multiple echocardiographic parameters.•The test characteristics of echocardiography for pulmonary embolism are similar between cardiologists, cardiac sonographers, and physicians trained in point of care ultrasound.•Overall, echocardiography should not be used alone as test to rule out pulmonary embolism.•Findings of right heart strain on transthoracic echocardiography can guide management, especially in scenarios where confirmatory studies are either not available (resource-limited settings) or feasible (critically ill patients).