Diagnostic Strategies for Suspected Pulmonary Embolism Among Outpatients

 

 Buy Article Permissions and Reprints

ABSTRACT

Diagnosis of pulmonary embolism (PE) has been made easier, less invasive, and somewhat safer over the past 2 decades. This has been due mainly to the development of lung scan and to the recognition of VTE as an entity comprising deep vein thrombosis and PE. The prevalence of the disease in patients clinically suspected of PE has steadily decreased during the past 10 years. This has led to the development of diagnostic tools that aim at reducing the number of unnecessary pulmonary angiograms. These include clinical probability assessment and fibrin D-dimer. Several strategies combining these tools have been validated in large outcome studies and compared in a formal cost-effectiveness analysis. The results indicate that they should now be implemented in daily practice taking into account local facilities and expertise. The exact place of helical computed tomography in such sequential algorithms remains to be established.

REFERENCES

• 1 The PIOPED Investigators. Value of the ventilation-perfusion scan in acute pulmonary embolism.  JAMA . 1990;  263 2753-2759
  Google Scholar
• 2 Stein P D, Athanasoulis C, Alavi A. Complications and validity of pulmonary angiography in acute pulmonary embolism.  Circulation . 1992;  85 462-468
  PubMedGoogle Scholar
• 3 Wells P S, Ginsberg J S, Anderson D R. Use of a clinical model for safe management of patients with suspected pulmonary embolism.  Ann Intern Med . 1998;  129 997-1005
  Google Scholar
• 4 Perrier A, Desmarais S, Miron M J. Non-invasive diagnosis of venous thromboembolism in outpatients.  Lancet . 1999;  353 190-195
  Google Scholar
• 5 Perrier A, Miron M J, Desmarais S. Using clinical evaluation and lung scan to rule out suspected pulmonary embolism: is it a valid option in patients with normal results of lower-limb venous compression ultrasonography?.  Arch Intern Med . 2000;  160 512-516
  CrossrefPubMedGoogle Scholar
• 6 Wells P S, Anderson D R, Rodger M. Derivation of a simple clinical model to categorize patients' probability of pulmonary embolism: increasing the models utility with the SimpliRED DD.  Thromb Haemost . 2000;  83 416-420
  Article in Thieme ConnectPubMedGoogle Scholar
• 7 Miniati M, Prediletto R, Formichi B. Accuracy of clinical assessment in the diagnosis of pulmonary embolism.  Am J Respir Crit Care Med . 1999;  159 864-871
  CrossrefPubMedGoogle Scholar
• 8 Bounameaux H, de Moerloose P, Perrier A, Miron M J. D-dimer testing in suspected venous thromboembolism: an update.  QJM . 1997;  90 437-42
  CrossrefPubMedGoogle Scholar
• 9 Ginsberg J S, Wells P S, Kearon C. Sensitivity and specificity of a rapid whole-blood assay for D-dimer in the diagnosis of pulmonary embolism.  Ann Intern Med . 1998;  129 1006-1011
  PubMedGoogle Scholar
• 10 Freyburger G, Trillaud H, Labrouche S, Gauthier P, Javorschi S, Grenier N. Rapid ELISA D-dimer testing in the exclusion of venous thromboembolism in hospitalized patients.  Clin Appl Thromb Hemost . 2000;  6 77-81
  PubMedGoogle Scholar
• 11 Owings J T, Gosselin R C, Battistella F D, Anderson J T, Petrich M, Larkin E C. Whole blood D-dimer assay: an effective noninvasive method to rule out pulmonary embolism.  J Trauma . 2000;  48 795-799
  PubMedGoogle Scholar
• 12 Perrier A, Bounameaux, H. Diagnosis of pulmonary embolism in outpatients by sequential noninvasive tools.  Semin Thromb Hemost . 2001;  27 25-32
  Article in Thieme ConnectPubMedGoogle Scholar
• 13 Kearon C, Ginsberg J S, Hirsh J. The role of ultrasonography in the diagnosis of suspected deep venous thrombosis and pulmonary embolism.  Ann Intern Med . 1998;  129 1044-1049
  Google Scholar
• 14 Shah A A, Davis S D, Gamsu G, Intriere L. Parenchymal and pleural findings in patients with and patients without acute pulmonary embolism detected at spiral CT.  Radiology . 1999;  211 147-153
  PubMedGoogle Scholar
• 15 Mullins M D, Becker D M, Hagspiel K D, Philbrick J T. The role of spiral volumetric computed tomography in the diagnosis of pulmonary embolism.  Arch Intern Med . 2000;  160 293-298
  CrossrefPubMedGoogle Scholar
• 16 Rathbun S W, Raskob G E, Whitsett T L. Sensitivity and specificity of helical computed tomography in the diagnosis of pulmonary embolism: a systematic review.  Ann Intern Med . 2000;  132 227-232
  PubMedGoogle Scholar
• 17 Greaves S M. CT of pulmonary thromboembolism.  Semin Ultrasound CT MR . 1997;  18 323-337
  CrossrefPubMedGoogle Scholar
• 18 Goodman L R. Helical CT for initial imaging of pulmonary embolus.  AJR Am J Roentgenol . 1998;  171 1153-1154
  PubMedGoogle Scholar
• 19 Goodman L R. CT of acute pulmonary emboli: where does it fit?.  Radiographics . 1997;  17 1037-1042
  PubMedGoogle Scholar
• 20 Remy-Jardin M, Remy J, Artaud D, Fribourg M, Beregi J P. Spiral CT of pulmonary embolism: diagnostic approach, interpretative pitfalls and current indications.  Eur Radiol . 1998;  8 1376-1390
  CrossrefPubMedGoogle Scholar
• 21 Ferretti G R, Bosson J L, Buffaz P D. Acute pulmonary embolism: role of helical CT in 164 patients with intermediate probability at ventilation-perfusion scintigraphy and normal results at duplex US of the legs.  Radiology . 1997;  205 453-458
  PubMedGoogle Scholar
• 22 Perrier A, Howarth N, Didier D. Performance of helical computed tomography in unselected patients with suspected pulmonary embolism.  Ann Intern Med . 2001;  135 88-97
  PubMedGoogle Scholar
• 23 Dalen J E, Brooks H L, Johnson L W, Meister S G, Szues M M, Dexter L. Pulmonary angiography in acute pulmonary embolism: indications, techniques, and results in 367 patients.  Am Heart J . 1971;  81 175-185
  CrossrefPubMedGoogle Scholar
• 24 Mills S R, Jackson D C, Older R A, Heaston D K, Moore A V. The incidence, etiologies, and avoidance of complications of pulmonary angiography in a large series.  Radiology . 1980;  136 295-299
  PubMedGoogle Scholar
• 25 Perlmutt L M, Braun S D, Newman G E, Oke E J, Dunninck N R. Pulmonary arteriography in the high risk patient.  Radiology . 1987;  162 187-189
  PubMedGoogle Scholar
• 26 Hudson E R, Smith T P, McDermott V G. Pulmonary angiography performed with iopamidol: complications in 1434 patients.  Radiology . 1996;  198 61-65
  PubMedGoogle Scholar
• 27 De Groot R M, van Marwijk Kooy M, Pouwels J G, Engelage A H, Kuipers B F, Büller H R. The use of a rapid D-dimer blood test in the diagnostic work-up for pulmonary embolism: a management study.  Thromb Haemost . 1999;  82 1588-1592
  PubMedGoogle Scholar
• 28 Wells P S, Anderson D R, Kovacs M. Management of patients with suspected pulmonary embolism presenting to the emergency department using clinical probability and D-dimer [abstract].  Thromb Haemost . 1999;  (suppl) 82
  PubMedGoogle Scholar
• 29 Oudkerk M, van Beek J E, van Putten L W, Büller H R. Cost-effectiveness analysis of various strategies in the diagnostic management of pulmonary embolism.  Arch Intern Med. 1993;  153 947-954
  CrossrefPubMedGoogle Scholar
• 30 Perrier A, Sarasin F P, Howarth N, Bounameaux H. Diagnostic strategies for suspected pulmonary embolism including helical CT scan: A cost-effectiveness analysis [abstract].  Thromb Haemost. 2001;  Suppl Abstr P1545
  PubMedGoogle Scholar
• 31 Berghout A, Oudkerk M, Hicks S G, Teng T H, Pillay M, Buller H R. Active implementation of a consensus strategy improves diagnosis and management in suspected pulmonary embolism.  QJM . 2000;  93 335-340
  CrossrefPubMedGoogle Scholar