Chest
Volume 145, Issue 5, May 2014, Pages 950-957
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Original Research Pulmonary Procedures Featured
Accuracy of Point-of-Care Multiorgan Ultrasonography for the Diagnosis of Pulmonary Embolism

https://doi.org/10.1378/chest.13-1087Get rights and content

Background

Presenting signs and symptoms of pulmonary embolism (PE) are nonspecific, favoring a large use of second-line diagnostic tests such as multidetector CT pulmonary angiography (MCTPA), thus exposing patients to high-dose radiation and to potential serious complications. We investigated the diagnostic performance of multiorgan ultrasonography (lung, heart, and leg vein ultrasonography) and whether multiorgan ultrasonography combined to Wells score and D-dimer could safely reduce MCTPA tests.

Methods

Consecutive adult patients suspected of PE and with a Wells score > 4 or a positive D-dimer result were prospectively enrolled in three EDs. Final diagnosis was obtained with MCTPA. Multiorgan ultrasonography was performed before MCTPA and considered diagnostic for PE if one or more subpleural infarcts, right ventricular dilatation, or DVT was detected. If multiorgan ultrasonography was negative for PE, an alternative ultrasonography diagnosis was sought. Accuracies of each single-organ and multiorgan ultrasonography were calculated.

Results

PE was diagnosed in 110 of 357 enrolled patients (30.8%). Multiorgan ultrasonography yielded a sensitivity of 90% and a specificity of 86.2%, lung ultrasonography 60.9% and 95.9%, heart ultrasonography 32.7% and 90.9%, and vein ultrasonography 52.7% and 97.6%, respectively. Among the 132 patients (37%) with multiorgan ultrasonography negative for PE plus an alternative ultrasonographic diagnosis or plus a negative D-dimer result, no patients received PE as a final diagnosis.

Conclusions

Multiorgan ultrasonography is more sensitive than single-organ ultrasonography, increases the accuracy of clinical pretest probability estimation in patients with suspected PE, and may safely reduce the MCTPA burden.

Trial registry

ClinicalTrials.gov; No.: NCT01635257; URL: www.clinicaltrials.gov

Section snippets

Design, Setting, Protocol, and Population

This was a multicenter prospective accuracy study, and the local ethic committees approved the study (No. 2012/20938 and 2012/5069). Written informed consent was obtained for inclusion in the study. The patients were recruited from June 2012 to November 2012 in the ED of three Italian hospitals: two university hospitals with an annual census of 120,000 and 50,000 visits, respectively, and one community hospital with an annual census of 50,000 visits.

Consecutive patients aged > 18 years,

Results

A total of 510 patients with clinically suspected PE presented to the EDs. Ninety-seven patients (19%) had a Wells score ≤ 4 and a negative D-dimer and were not considered for the study. Among the 413 patients with a Wells score > 4 or a positive D-dimer, 56 (13.6%) were excluded because they met exclusion criteria (Fig 1); thus, 357 patients were included. Included patients had a mean age of 71 ± 14 years (range, 19-100 years), and 188 (52.7%) were women. PE was diagnosed by MCTPA in 110

Discussion

This study indicates that multiorgan ultrasonography is feasible in almost all patients presenting to the ED with suspected PE. Multiorgan ultrasonography sensitivity is significantly superior to that of lung, heart, and leg vein ultrasonography alone; our multiorgan protocol may be useful as a routine pretest evaluation to improve the potential of Wells scoring and D-dimer assay in the selection of patients who should undergo MCTPA.

Today, MCTPA has become the standard of care in patients with

Limitations and Conclusions

Multiorgan ultrasonography tests were performed in the ED by emergency physicians with at least 2 years' experience in ultrasonography. Application of the same methodology by physicians with less experience may lower accuracy and safety. Moreover, the accuracy of multiorgan ultrasonography performed in different settings, such as inpatient or outpatient clinics, may be different. Another note is that patients with contraindications to MCTPA were excluded from our study.

Multiorgan

Acknowledgments

Author contributions: Dr Nazerian is the guarantor of the manuscript.

Dr Nazerian: contributed to study conception and design and data acquisition, analysis, and interpretation; drafted the manuscript; edited the manuscript for important intellectual and scientific content; served as the principal author; edited the revision; and approved the final draft.

Dr Vanni: contributed to study conception and design, conducted statistical analysis, drafted the manuscript, edited the revision, and approved

References (37)

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For editorial comment see page 931

Funding/Support: The authors have reported to CHEST that no funding was received for this study.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.

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