ABSTRACT
Patients with unprovoked venous thromboembolism (VTE) may harbor occult cancer. Whether an extensive diagnostic work-up for cancer has additional value over a more limited screening for detection of underlying malignancy in these patients is controversial. We performed a randomized multicenter trial to assess if in patients with unprovoked VTE, a computed tomography (CT)-based diagnostic strategy including thoracic, abdominal, and pelvic CT in combination with fecal occult blood test yields a higher cancer detection rate than a nonstandardized testing approach based on physicians' clinical judgment and patients' preferences. Cancer-free patients were followed up for up to 24 months. Of the 195 consecutive patients with unprovoked VTE who were eligible for this investigation, an occult cancer was identified in 10 of the 98 patients (10.2%) randomized to the CT-based strategy, and in 8 of the 97 (8.2%) allocated to the personalized strategy (absolute difference, 2.0%; 95% confidence interval, -7.2-11.1; p = 0.81). During follow-up, cancer was identified in an additional 2 patients in each group. Overall, 7 (7.1%) patients of the CT-based strategy died, as compared with 11 (11.3%) of the personalized strategy, with 2 and 4, respectively, due to cancer. In conclusion, a CT-based strategy in combination with fecal occult blood test does not provide a clinically significant benefit over more limited cancer screening for detecting occult cancer in patients with unprovoked VTE. (ClinicalTrials.gov number, NCT00361647).
Subject(s)
Early Detection of Cancer/methods , Tomography, X-Ray Computed/methods , Venous Thromboembolism/diagnostic imaging , Female , Humans , Male , Venous Thromboembolism/diagnosisABSTRACT
BACKGROUND: The management of patients with acute chest pain is a common and difficult challenge from the epidemiological, clinical, organizational and malpractice points of view. Our purpose was to test and implement a simple clinical protocol for the management of patients with acute chest pain and at low-risk for an acute coronary syndrome (ACS) at the time of admission to the Emergency Department (ED). METHODS: During a 5-month study period, 570 consecutive patients were admitted to the ED with acute chest pain: 224 patients were excluded owing to the presence of a clear diagnosis of an ACS or of high-risk factors. The remaining 346 were considered, at the time of admission, as being at low risk for an ACS and constituted the study group (208 males, 138 females, mean age 65 years). These 346 patients were evaluated in the ED area by means of multiple ECGs and multiple blood sampling for the creatine kinase-MB mass and troponin I serum levels at the time of admission and 6 and 12 hours later. In selected cases a treadmill stress test was requested in order to further clarify the diagnosis. RESULTS: The ECG at the time of admission was normal or nearly normal in 79% of the patients. Stress testing was performed in 79 patients (25%). Sixty-six/346 low-risk patients (19%) were admitted to the coronary care unit during ED observation: 38 patients because of positive markers, 10 because of a positive ECG, 13 because of positive markers and ECG, and 5 because of a positive stress test. Two hundred and eighty low-risk patients without evidence of acute ischemia were definitively discharged and classified as having non-ischemic chest pain. At 1 month of follow-up, 1 patient underwent coronary artery bypass grafting, 1 patient was again admitted to the ED for acute pulmonary edema, and 2 patients had acute extracardiac events. Within 1 year of follow-up 4 deaths occurred: 2 were cancer-related and 2 were sudden deaths. CONCLUSIONS: The tested strategy, based on integrated clinical, ECG and multimarker data, and on a short "test of time" period of low-risk patient observation, can allow the identification of patients having an ACS on the one hand and of those for whom a safe, rapid and early discharge is possible on the other, in a low-cost environment.
