PESIT and PATCH it! – Plugging ICH with platelets and quantifying the prevalence of PE in syncope


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It’s so hot you can barely touch it – the PESIT study! So what’s the buzz all about? Pulmonary embolism is one of those dreaded diagnoses – it can be life-threatening, but often elusive in its diagnosis since so many other conditions cause similar symptoms. Kieran takes listeners through the multi-centre cross sectional PESIT study which sought to quantify the prevalence of pulmonary embolism in patients who present with syncope. Following analysis of the article, the implications for future practice are discussed.

Then, Lauren Lacroix, Chief Resident in Emergency Medicine at the University of Ottawa, takes listeners through the PATCH trial. Hemorrhagic stroke is associated with substantial morbidity and mortality, and acute treatment has yet to be perfected. This international multicenter, open-label, randomized controlled trial was designed to compare treatments in patients with acute spontaneous primary intracerebral hemorrhage by answering the following question: is platelet transfusion better than standard care? Listen to find out!

Finally, how does daylight savings time affect your health? And what are the costs of not offering paid sick leave? The Good Stuff segment has the answers!

Like our show? Rate us on iTunes! Give us a shout on Twitter @roundstable. Tweet at this week’s hosts directly @kieranlquinn & @llacroix4

The Papers

1. PESIT: http://www.nejm.org/doi/full/10.1056/NEJMoa1602172#t=article

2. PATCH: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)30392-0/abstract

Good Stuff

1. Sick Leave: http://www.nytimes.com/2016/11/01/upshot/the-high-costs-of-not-offering-paid-sick-leave.html?_r=0

2. Car Crashes & Daylight Savings: http://www.cbc.ca/news/canada/daylight-saving-time-facts-figures-1.3485261

Music Credits (Creative Commons)

In your Robotic Heart – Nicolai Heidlas https://soundcloud.com/nicolai-heidlas/in-your-robotic-heart

Drive – Nicolai Heidlas https://soundcloud.com/nicolai-heidlas/drive-fresh-upbeat-pop-background-music

Vintage Dream – Nicolai Heidlas https://soundcloud.com/nicolai-heidlas/vintage-dream-loungejazzy-background-music

All tracks have been modified for the purposes of this podcast.

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2 comments

  1. Andreas Laupacis

    Hi Kieran and Lauren. Thanks for this podcast. The results of the PESIT trial are pretty remarkable (17% of patients admitted with unexplained syncope had a pulmonary embolism). I was surprised that you both said this study wouldn’t change your practice, even though you said it was a well done study. If I was 76 years old and my syncope was worrisome enough for Kieran to admit me to GIM, on the basis of this study I would be asking Kieran to do a VQ or CT scan. What am I missing?

    • Kieran Quinn

      Hello Andreas,

      Thank you for your question. Indeed the findings of this study are surprising, but the interpretation should be taken with a cautionary approach!

      I think there is great hazard in extrapolating these results (and thereby implementing a more algorithmic testing strategy) to a broader population of individuals with syncope when taking into account the clinical signs of those who ultimately had PE (signs of DVT in 40 versus 5% who did not; tachycardia in 36 versus 23%, tachypnea in 45 versus 7%). I think an astute clinician should be able to recognize those patients who are more likely to have a PE, even after they are admitted to hospital without a clear inciting prodrome or description, given the above clinical presentations.

      The study also did not report the rates of adverse outcomes (such as contrast-induced nephropathy) from the CTPAs that were conducted in the 180 patients (versus 49 for V/Q) as a counter balance to the identification of VTE (which in some cases could have been identified using doppler ultrasonography of the lower extremities).

      My practice pattern is currently as such: if a patient’s history of syncope is not definitive for an alternate cause, and/or they have major underlying cardiac disease, then I currently assess their risk of VTE using the Well’s score and proceed with CTPA or V/Q if it is “PE likely”.

      With regards to changing my practice: if ordering d-dimers more often for the specific subset of patients admitted with first episode syncope who have no other good identifiable etiology BEFORE (or concurrently) I assess their Well’s score and proceed accordingly is considered changing practice – then I submit. But to me, that is not a major shift in the winds of my practice, only a minor alteration in my ship’s course.

      Perhaps it is simply semantics in one’s definition of “changing practice”?

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