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Differences of computed tomography pulmonary angiography versus ventilation-perfusion lung scan in pregnant patients with suspected acute pulmonary embolism are not well-known, leading to ongoing debate on which test to choose. We searched in PUBMED, EMBASE, Web of science and Cochrane library databases and identified all relevant articles and abstracts published up to October1st 2017. We assessed diagnostic efficiency, frequency of non-diagnostic results and radiation exposure for patient and fetus. We included 13 studies for the diagnostic efficiency analysis, 30 for non-diagnostic results analysis and 22 for radiation exposure analysis. Pooled rate of false negative test results was 0% for both imaging strategies with overlapping confidence intervals. The pooled rate of non-diagnostic results with computed tomography pulmonary angiography and ventilation-perfusion lung scan were 12% (95%CI 8-17) and 14% (95%CI 10-18), respectively. Reported maternal and fetal radiation exposure doses were well below the safety threshold, but could not be compared between computed tomography pulmonary angiography and ventilation-perfusion lung scan given the lack of high quality data. Both imaging tests seem equally safe to rule out PE in pregnancy. We found no significant differences in efficiency and radiation exposures between computed tomography pulmonary angiography and ventilation-perfusion lung scan although direct comparisons were not possible. .

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Background In patients suspected of pulmonary embolism (PE), clinical decision rules are combined with D-dimer testing to rule out PE, avoiding the need for imaging in those at low risk. Despite sex differences in several aspects of the disease, including its diagnosis, these algorithms are used indiscriminately in women and men. Objectives To compare the performance, defined as efficiency and failure rate, of three pre-imaging diagnostic algorithms for PE between women and men: the Wells rule with fixed or with age-adjusted D-dimer cut-off, and a recently validated algorithm (YEARS). A secondary aim was to determine the sex-specific prevalence of PE. Methods Individual patient data were obtained from six studies using the Wells rule (fixed D-dimer, n = 5; age adjusted, n = 1) and from one study using the YEARS algorithm. All studies prospectively enrolled consecutive patients with suspected PE. Main outcomes were efficiency (proportion of patients in which the algorithm ruled out PE without imaging) and failure rate (proportion of patients with PE not detected by the algorithm). Outcomes were estimated using (multilevel) logistic regression models. Results The main outcomes showed no sex differences in any of the separate algorithms. With all three, the prevalence of PE was lower in women (OR, 0.66, 0.68 and 0.74). In women, estrogen use, adjusted for age, was associated with lower efficiency and higher prevalence and D-dimer levels. Conclusions The investigated pre-imaging diagnostic algorithms for patients suspected of PE show no sex differences in performance. Male sex and estrogen use are both associated with a higher probability of having the disease.

SummaryThe rate of identified isolated subsegmental pulmonary embolism (ssPE) has doubled with advances in computed tomography pulmonary angiography (CTPA) technology, but its clinical relevance is debated. The YEARS diagnostic algorithm was shown to safely reduce the number of required CTPAs in the diagnostic management of PE. We hypothesized that the higher threshold for performing CTPA in YEARS was associated with a lower prevalence of ssPE compared to the conventional diagnostic algorithm. We compared 2291 consecutive patients with suspected PE managed according to YEARS to 3306 consecutive control patients managed according to the Wells score for the prevalence of isolated ssPE. In the YEARS cohort, 52% were managed without CTPA, 12% had pulmonary embolism (PE) of which 10% were isolated ssPE, and the 3‐month diagnostic failure rate was 0·35%. In the control cohort, 32% were managed without CTPA, 20% had PE of which 16% were isolated ssPE, and the 3‐month failure rate was 0·73%. The isolated ssPE prevalence was significantly lower in YEARS (absolute difference 6·2% (95% confidence interval [CI] 1·4–10), Odds Ratio 0·58 (95% CI 0·37–0·90). In conclusion, YEARS is associated with a lower prevalence of isolated ssPE, due to reduction in CTPAs by the higher D‐dimer threshold. This was however not associated with a higher risk of recurrent VTE during follow‐up.