Diagnosing pulmonary embolism in outpatients, with clinical assessment, D-Dimer measurement, venous ultrasound, and helical computed tomography: a multicenter management study

Perrier, Arnaud; Roy, Preety Mittal; Aujesky, Drahomir; Chagnon, Isabelle

doi:10.1016/j.accreview.2004.04.085

Cited by 118 publications

(243 citation statements)

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“…An apriori acceptable upper limit of the 95% CI for the 3-month thromboembolic risk was 4%, a limit accepted in similar outcome studies on PE [5,6,9].…”

Section: Discussionmentioning

confidence: 99%

“…The role of spiral CT in the diagnosis of PE has been extensively evaluated in recent years [6,9,[11][12][13][14]. The main impediment for single slice spiral CT has been the limitation of this modality to detect small peripheral emboli [2,15].…”

Section: Introductionmentioning

confidence: 99%

“…Its role is therefore mainly limited to the exclusion of VTE in outpatients [4]. Depending on the assay, D-dimer can reliably exclude PE in up to 30% of outpatients [5,6].…”

Section: Introductionmentioning

confidence: 99%

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Management of suspected pulmonary embolism (PE) by D‐dimer and multi‐slice computed tomography in outpatients: an outcome study

Ghanima

Almaas

Aballi

et al. 2005

Journal of Thrombosis and Haemostasis

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To cite this article: Ghanima W, Almaas V, Aballi S, Dö rje C, Nielssen BE, Holmen LO, Almaas R, Abdelnoor M, Sandset PM. Management of suspected pulmonary embolism (PE) by D-dimer and multi-slice computed tomography in outpatients: an outcome study. J Thromb Haemost 2005; 3: 1926-32.See also Schoepf UJ. Computed tomography for pulmonary embolism diagnosis: the making of a reference standard. This issue, pp 1924-5.Summary. Objectives: A prospective outcome study designed to evaluate a simple strategy for the management of outpatients with suspected pulmonary embolism (PE), based on clinical probability, D-dimer, and multi-slice computed tomography (MSCT). Methods: A cohort of 432 consecutive patients admitted to the emergency department with suspected PE was managed by sequential non-invasive testing. Patients in whom PE was ruled out were not given anticoagulants, but were followed-up for 3 months. Results: Normal D-dimer and lowintermediate clinical probability ruled out PE in 103 patients [24% (95% CI 20-28)]. Seventeen patients had normal D-dimer, but high clinical probability and proceeded to MSCT. All patients proved negative for PE. A total of 329 (76%) patients underwent MSCT examination. Pulmonary embolism was diagnosed in 93 patients [21.5% (95% CI 18-26)] and was ruled out by negative MSCT in 221 patients [51% (95% CI 46-56)]. MSCT scans were determined as inconclusive in 15 (4.5%) patients. No patient developed objectively verified venous thromboembolism (VTE) during the 3-month follow-up period. However, the cause of death was adjudicated as possibly related to PE in two patients, resulting in an overall 3-month VTE risk of 0.6% (95% CI 0-2.2%). The diagnostic algorithm yielded a definite diagnosis in 96.5% of the patients. Conclusions: This simple and non-invasive strategy combining clinical probability, D-dimer, and MSCT for the management of outpatients with suspected PE appears to be safe and effective.

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“…An apriori acceptable upper limit of the 95% CI for the 3-month thromboembolic risk was 4%, a limit accepted in similar outcome studies on PE [5,6,9].…”

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Management of suspected pulmonary embolism (PE) by D‐dimer and multi‐slice computed tomography in outpatients: an outcome study

Ghanima

Almaas

Aballi

et al. 2005

Journal of Thrombosis and Haemostasis

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“…In management trials, this approach resulted in a low false-negative rate (1.0%-1.8% at 3-month follow-up). [11][12][13][14] However, the rate of major bleeding in patients treated for PE was 3.2%-6.0% at 3 months, [12][13][14] illustrating the potential risk of anticoagulating patients who may have false-positive diagnoses. Furthermore, premature diagnostic closure after a CTPA "positive for PE" may result in additional morbidity as a result of missing the true diagnosis.…”

Section: Discussionmentioning

confidence: 99%

“…27 Plasma D-dimer testing is not routinely used at our hospitals, but it is a component of some CTPAbased diagnostic algorithms. [11][12][13][14] Although use of D-dimer testing may have led to fewer scans in patients with negative D-dimer test results and low pretest probability, 30 the high false-positive rate for D-dimer assays 31 makes it difficult to predict the effect of widespread D-dimer use on the overall pretest probability distribution. Using our assumptions about CT test characteristics, a pretest probability of more than 30% is required to generate a posttest probability of PE of at least 90% (the traditional treatment threshold for anticoagulant therapy 22 ) with a positive scan.…”

Section: Discussionmentioning

confidence: 99%

Impact of reliance on CT pulmonary angiography on diagnosis of pulmonary embolism: A Bayesian analysis

Ranji

Shojania

Trowbridge

et al. 2006

Journal of Hospital Medicine

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BACKGROUNDSpiral computed tomographic pulmonary angiography (CTPA) has become the primary test used to investigate suspected pulmonary embolism (PE) at many institutions, despite uncertainty regarding its sensitivity and specificity. Although CTPA‐based diagnostic algorithms focus on minimizing the false‐negative rate, we hypothesized that increasing use of CTPA also might lead to false‐positive diagnoses.OBJECTIVEDetermine the frequency of possible false‐positive diagnoses of PE when CTPA is the primary diagnostic test.DESIGNRetrospective cohort study.SETTINGTwo academic teaching hospitals.PARTICIPANTS322 patients with suspected PE evaluated with CTPA.MEASUREMENTSWe used a validated prediction rule to determine the pretest probability of PE in each patient. We combined these pretest probabilities with published estimates of CTPA test characteristics to generate expected posttest probabilities of PE. We compared these posttest probabilities to actual treatment decisions to determine the rate of false‐positive diagnoses of PE.RESULTSAmong 322 patients investigated for PE, 37 (12%) had high pretest probability, 101 (32%) moderate, and 184 (57%) low. CT scans were interpreted as positive for PE in 57 patients (17.8%). Regardless of the pretest probability of PE, 96.5% of patients with a positive CTPA were treated with anticoagulants. Even under an optimistic assumption of CTPA test characteristics, as many as 25.4% of these patients may have been treated unnecessarily as a result of a false‐positive diagnosis. Most of these patients had a low pretest probability of PE.CONCLUSIONSFailure to utilize Bayesian reasoning when interpreting CTPA may lead to false‐positive diagnoses of pulmonary embolism in a substantial proportion of patients. Journal of Hospital Medicine 2006;1:81–87. © 2006 Society of Hospital Medicine

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Clinical Usefulness of D-Dimer Depending on Clinical Probability and Cutoff Value in Outpatients With Suspected Pulmonary Embolism

Righini

Aujesky²,

Roy³

et al. 2004

Arch Intern Med

101

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Diagnosing pulmonary embolism in outpatients, with clinical assessment, D-Dimer measurement, venous ultrasound, and helical computed tomography: a multicenter management study

Cited by 118 publications

References 0 publications

Management of suspected pulmonary embolism (PE) by D‐dimer and multi‐slice computed tomography in outpatients: an outcome study

Management of suspected pulmonary embolism (PE) by D‐dimer and multi‐slice computed tomography in outpatients: an outcome study

Impact of reliance on CT pulmonary angiography on diagnosis of pulmonary embolism: A Bayesian analysis

Clinical Usefulness of D-Dimer Depending on Clinical Probability and Cutoff Value in Outpatients With Suspected Pulmonary Embolism

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