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increases with age&#44; it is expected that more cases of PE will be diagnosed in the future&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Within the study group&#44; 22&#37; of patients had been diagnosed with cancer prior to PE&#46; Although venous thromboembolism &#40;VTE&#41; is considered a consequence of the interaction between persistent risk factors and the temporal trigger factors&#44; cancer remains an important risk factor for all-cause mortality after episodes of VTE&#46; In the present study no significant difference was found between the presence of cancer and the extent of disease&#46; Dyspnea was the most common symptom in patients with central PE &#40;68&#37; of cases&#41; and pain was also a common symptom in segmental and subsegmental PE &#40;25&#37; and 7&#37;&#44; respectively&#41;&#46; PE patients frequently present with chest pain which is usually caused by pleural irritation due to distal embolisms&#44; causing pulmonary infarction&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Rapid onset of dyspnea is usually due to central PE and may be associated with angina-like pain reflecting right ventricle ischemia&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The authors report that subsegmental PE accounted for 7&#37; of cases&#59; these patients were younger&#44; had lower comorbidity and none of them presented proximal deep venous thrombosis &#40;DVT&#41;&#46; This contrasts with the reported presence of DVT in 70&#37; of patients with proven PE&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">This calls into question the clinical significance of isolated subsegmental PE on CT&#46; This finding was present in 9&#46;4&#37; of those who underwent a CT&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The positive value is low and an interobserver variation is high at subsegmental level&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> In this situation&#44; is advisable to perform compression venous ultrasonography to ensure that the patients does not have DVT that it should be treated&#46; This echography assessment showed DVT in 30&#8211;50&#37; of patients with PE&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The incidental finding of clinically unsuspected PE on CT is a growing problem&#44; that occurs in 1&#8211;2&#37; of thoracic CT examinations&#44; more often in patients with cancer&#44; but also in patients with heart failure or atrial fibrillation&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a> Additional testing may be needed to confirm PE in case of isolated subsegmental thrombi&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The authors reported a 30 days mortality rate of 7&#37;&#44; attributable to PE in 3&#46;5&#37; of cases&#46; None of the patients died as a result of subsegmental PE&#46; They also found that factors independently related to a higher likelihood of mortality were cancer diagnosis and higher comorbidity&#46; In the Spanish registry RIETE&#44; immobility due to neurological involvement&#44; presence of cancer and old age were independently correlated with increased short-term mortality&#44; following an episode of VTE&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">It is an accepted fact that acute right ventricular failure is a major determinant to predict prognosis after acute episode of PE&#46; The presence of sustained arterial hypotension and cardiogenic shock is indicative of poor prognosis in the short term follow-up&#46; Garc&#237;a Sanz et al&#46; do not provide information on the distribution of high-risk patients in relation to the extent of PE and the influence it could have on RV failure in the short-term prognosis&#46; Possibly this is inherent in the design of the study &#8211; a retrospective design and single center &#8211; one of the major limitations&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The authors discuss the uncertain clinical significance of subsegmental PE&#44; suggesting that the prognosis is associated more with the presence of accompanying disorders than the extent of the disease&#46;Although there have been many advances in the management of PE&#44; a number of justifiable doubts persist&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">In a patient with isolated subsegmental PE without proximal DVT&#44; anticoagulation decision should be based on a balance between the risk of bleeding and diagnostic probability&#46;The original article under this editorial brings additional experience and helps us to individualize decisions&#46;</p></span>"
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Editorial
What is the clinical significance of isolated subsegmental pulmonary embolism?
Qual a revelância clínica da embolia pulmonar subsegmentar isolada?
M.A. Gómez-Sánchez
Cardiology Service, Hospital Universitario, 12 de Octubre, CIBERES, Madrid, Spain
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            "entidad" => "Cardiology Service&#44; Hospital Universitario&#44; 12 de Octubre&#44; CIBERES&#44; Madrid&#44; Spain"
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    "titulosAlternativos" => array:1 [
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        "titulo" => "Qual a revel&#226;ncia cl&#237;nica da embolia pulmonar subsegmentar isolada&#63;"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In this original article&#44; Garcia-Sanz et al&#46; assess survival prognosis in a group of patients diagnosed with pulmonary embolism &#40;PE&#41; by chest computed tomography &#40;CT&#41;&#46; The study included 313 PE patients&#44; 56&#37; were women and the median age was 70 years old&#46; The objective was to describe the clinical profile of patients with PE and to analyze their prognosis based on the extent of the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The epidemiology of PE is difficult to determine because it can be asymptomatic or result in sudden death&#46; Only a very small percentage of fatal cases are diagnosed while the patient is alive&#46; PE is a major cause of morbidity and mortality in developed countries&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Since the incidence of deep venous thrombosis &#40;DVT&#41; increases with age&#44; it is expected that more cases of PE will be diagnosed in the future&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Within the study group&#44; 22&#37; of patients had been diagnosed with cancer prior to PE&#46; Although venous thromboembolism &#40;VTE&#41; is considered a consequence of the interaction between persistent risk factors and the temporal trigger factors&#44; cancer remains an important risk factor for all-cause mortality after episodes of VTE&#46; In the present study no significant difference was found between the presence of cancer and the extent of disease&#46; Dyspnea was the most common symptom in patients with central PE &#40;68&#37; of cases&#41; and pain was also a common symptom in segmental and subsegmental PE &#40;25&#37; and 7&#37;&#44; respectively&#41;&#46; PE patients frequently present with chest pain which is usually caused by pleural irritation due to distal embolisms&#44; causing pulmonary infarction&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Rapid onset of dyspnea is usually due to central PE and may be associated with angina-like pain reflecting right ventricle ischemia&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The authors report that subsegmental PE accounted for 7&#37; of cases&#59; these patients were younger&#44; had lower comorbidity and none of them presented proximal deep venous thrombosis &#40;DVT&#41;&#46; This contrasts with the reported presence of DVT in 70&#37; of patients with proven PE&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">This calls into question the clinical significance of isolated subsegmental PE on CT&#46; This finding was present in 9&#46;4&#37; of those who underwent a CT&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The positive value is low and an interobserver variation is high at subsegmental level&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> In this situation&#44; is advisable to perform compression venous ultrasonography to ensure that the patients does not have DVT that it should be treated&#46; This echography assessment showed DVT in 30&#8211;50&#37; of patients with PE&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The incidental finding of clinically unsuspected PE on CT is a growing problem&#44; that occurs in 1&#8211;2&#37; of thoracic CT examinations&#44; more often in patients with cancer&#44; but also in patients with heart failure or atrial fibrillation&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a> Additional testing may be needed to confirm PE in case of isolated subsegmental thrombi&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The authors reported a 30 days mortality rate of 7&#37;&#44; attributable to PE in 3&#46;5&#37; of cases&#46; None of the patients died as a result of subsegmental PE&#46; They also found that factors independently related to a higher likelihood of mortality were cancer diagnosis and higher comorbidity&#46; In the Spanish registry RIETE&#44; immobility due to neurological involvement&#44; presence of cancer and old age were independently correlated with increased short-term mortality&#44; following an episode of VTE&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">It is an accepted fact that acute right ventricular failure is a major determinant to predict prognosis after acute episode of PE&#46; The presence of sustained arterial hypotension and cardiogenic shock is indicative of poor prognosis in the short term follow-up&#46; Garc&#237;a Sanz et al&#46; do not provide information on the distribution of high-risk patients in relation to the extent of PE and the influence it could have on RV failure in the short-term prognosis&#46; Possibly this is inherent in the design of the study &#8211; a retrospective design and single center &#8211; one of the major limitations&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The authors discuss the uncertain clinical significance of subsegmental PE&#44; suggesting that the prognosis is associated more with the presence of accompanying disorders than the extent of the disease&#46;Although there have been many advances in the management of PE&#44; a number of justifiable doubts persist&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">In a patient with isolated subsegmental PE without proximal DVT&#44; anticoagulation decision should be based on a balance between the risk of bleeding and diagnostic probability&#46;The original article under this editorial brings additional experience and helps us to individualize decisions&#46;</p></span>"
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Pulmonology

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