Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism

Kline, Jeffrey A.; Mitchell, Alice M.; Kabrhel, Christopher; Richman, Peter B.; Courtney, D. Mark

doi:10.1111/j.1538-7836.2004.00790.x

Cited by 424 publications

(315 citation statements)

References 37 publications

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“…D-dimer is widely used clinically for the detection of in-vivo fibrin formation, and plasma levels of D-dimer are reported to be increased in patients with disseminated intravascular coagulation (DIC) [1,2], deep vein thrombosis (DVT)/pulmonary embolism (PE) [3][4][5][6], and acute myocardial infarction [7]. D-dimer has been adopted by the International Society of Thrombosis and Haemostasis as a diagnostic criterion of overt DIC [8].…”

Section: Introductionmentioning

confidence: 99%

Diagnosis of deep vein thrombosis by plasma-soluble fibrin or D-dimer

et al. 2005

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The present study was designed to determine the cutoff values of D-dimer and soluble fibrin (SF) for the diagnosis of deep venous thrombosis (DVT) and pulmonary embolism (PE) in Japanese patients. Plasma levels of these molecules were measured in 243 patients suspected of having DVT and 100 healthy volunteers (controls). Out of 243 patients, 20 patients were diagnosed with DVT. In the control group, plasma levels of D-dimer and SF did not show normal distribution, and the 95% confidence intervals (CI) of D-dimer and SF were 2.45 mg/mL and 6.92 mg/mL, respectively. Plasma levels of D-dimer and SF of patients with DVT were significantly higher than of those without DVT. In patients with DVT, the minimum values of D-dimer and SF were 1.71 and 1.44 mg/mL, respectively. When the cutoff value was set at the average + 1 SD of those of the control (D-dimer, about 1.8 mg/ mL; SF, about 1.4 mg/mL), 1 and 0 patient with DVT was overlooked, respectively. The sensitivity and specificity of D-dimer and SF for DVT were 95% and 100%, and 61.9% and 53.8%, respectively. When the cutoff value was set at 95% CI of the control (D-dimer, 2.5 mg/ mL; SF, 6.9 mg/mL), 2 and 9 patients with DVT were overlooked, respectively. The sensitivity and specificity of D-dimer and SF were 90% and 50%, and 77.6% and 88.3%, respectively. When the cutoff values set at 2.5 mg/mL of D-dimer or 6.9 mg/mL of SF, 1 DVT patient was overlooked, with sensitivity and specificity of 95% and 69.5%. Our data suggest that both D-dimer and SF are useful markers for the diagnosis of DVT and that measurement of both D-dimer and SF increases the sensitivity and specificity for the diagnosis of DVT/PE.

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Section: Introductionmentioning

confidence: 99%

Diagnosis of deep vein thrombosis by plasma-soluble fibrin or D-dimer

et al. 2005

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“…Tachycardia is a component of both the Wells prediction rule and the PERC criteria. 24,25 However, obesity can cause significant tachycardia, and the heart rate increases in a linear fashion with the BMI. 26 A 1984 study showed that respiratory rates in normal resting obese patients (body weight greater than 190% of predicted ideal weight) are typically 40% higher than non-obese patients.…”

Section: Signs and Symptoms Of Pe In Obese Patientsmentioning

confidence: 99%

“…22 Obesity itself is not included as a component of any of the commonly used standardized clinical decision rules to determine the clinical probability of PE including the Geneva score, the Wells prediction rule, or the PERC criteria used in emergency rooms to determine the need for additional testing in patients with suspected PE. [23][24][25] Tachycardia and tachypnea are the two most common signs found in PE. Tachycardia is a component of both the Wells prediction rule and the PERC criteria.…”

Section: Signs and Symptoms Of Pe In Obese Patientsmentioning

confidence: 99%

Difficulties in diagnosing pulmonary embolism in the obese patient: A literature review

Hawley

2011

Vasc Med

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Several of the signs and symptoms of pulmonary embolism, such as dyspnea, tachypnea, and tachycardia, are common in the obese population, so these patients are frequently suspected of having a pulmonary embolism. Establishing an accurate diagnosis in this situation is often difficult. We performed a review of the literature examining the difficulty of diagnosing pulmonary embolism in obese patients. Several factors compromise the ability of clinicians to accurately diagnose pulmonary embolism in obese patients. When patients weigh over 350 lbs (159 kg), thoracic imaging often cannot be performed because of the weight limitations of the scanning equipment. If equipment is available that can scan these patients, image quality is often poor. The literature that is available to guide the clinician in this difficult clinical scenario is sparse. Access to radiology equipment that can image morbidly obese patients is improving, but questions about image quality remain. Further research on both imaging and outcomes is needed.

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“…If the clinical gestalt is that PE is unlikely and all of the following variables are present, further testing can be safely discontinued: (1) pulse <100; (2) age <50; (3) oxygen saturation (SaO 2 ) >94%; (4) no unilateral leg swelling; (5) no hemoptysis; (6) no recent trauma or surgery; (7) no prior DVT or PE; and (8) no hormone use. 13 In a large, multicenter study, these criteria combined with a gestalt interpretation of low risk were shown to select a subgroup of patients with a very low probability of PE (<2%).…”

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confidence: 99%

“…13 The PERC rule consists of 8 variables designed to offer a pretest probability of PE of less than 1.8%, a probability at which further testing is unnecessary. If the clinical gestalt is that PE is unlikely and all of the following variables are present, further testing can be safely discontinued: (1) pulse <100; (2) age <50; (3) oxygen saturation (SaO 2 ) >94%; (4) no unilateral leg swelling; (5) no hemoptysis; (6) no recent trauma or surgery; (7) no prior DVT or PE; and (8) no hormone use.…”

mentioning

confidence: 99%