Diagnostic Strategies for Excluding Pulmonary Embolism in Clinical Outcome Studies

Kruip, Marieke J.H.A.; Leclercq, Monique; Heul, Cees van der; Prins, Martin H.; Büller, Harry R.

doi:10.7326/0003-4819-138-12-200306170-00005

Cited by 195 publications

(107 citation statements)

References 79 publications

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“…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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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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“…Several strategies for managing patients with suspected PE have been validated in recent years [21]. However, most of these strategies are complicated and involve multiple rounds of tests and are thus time consuming, costly and difficult to apply in clinical practice [5,6,9,11,22].…”

Section: Discussionmentioning

confidence: 99%

“…The MSCT images were unequivocally positive in 93 patients [21.5% (95% CI [18][19][20][21][22][23][24][25][26]]. In nine patients, the interpretations were less conclusive, but they were anticoagulated either on the basis of positive ultrasound finding of DVT in two cases or on the basis of clinical judgment supported by highly suggestive MSCT finding in the absence of an alternative diagnosis in the remaining seven patients.…”

Section: Positive Findings According To the Diagnostic Algorithmmentioning

confidence: 99%

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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“…La medición de marcadores de laboratorio como el dímero D de alta sensibilidad se recomienda para pacientes con baja probabilidad de TEP en las escalas de validación clínica con sensibilidad de 85% y valor predictivo negativo de 99% (65)(66)(67)(68)(69)(70) .…”

Section: Diagnóstico Embolismo Pulmonarunclassified

Tema 6-2015: Tromboembolismo Pulmonar: Fisiopatología Y Diagnóstico

Garzona

Navas

2015

RC_UCR-HSJD

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findings, analyzing the different advantages and disadvantages of each diagnostic tool. This article aims to provide a review of the epidemiology, pathophysiology and diagnosis of PE. KEY WORDSPulmonary Embolism, risk factors, pathophysiology, diagnosis. INTRODUCCIÓNEl tromboembolismo pulmonar (TEP) es una causa frecuente de hospitalización, asociada a importante morbilidad y mortalidad en múltiples contextos clínicos (1) . Este trabajo pretende brindar una revisión de la epidemiología, fisiopatología y diagnóstico del TEP. DISCUSIÓN Definición de Embolismo PulmonarLa incidencia de complicaciones asociadas al TEP debe contemplar la presencia de comorbilidades del paciente y su efecto sobre la evolución clínica posterior al embolismo. De esta manera, conviene establecer la definición del TEP en tres formas de presentación (1) :• Embolismo masivo • Embolismo submasivo • Embolismo de bajo riesgo El embolismo pulmonar masivo se caracteriza por la presencia de un cuadro agudo con hipotensión sostenida (presión arterial sistólica menor a 90 mmHg por al menos 15 minutos o que amerita soporte inotrópico o vasopresor), que no es atribuible a hipovolemia, sepsis, disfunción ventricular izquierda o arritmia; ausencia de pulso o bradicardia profunda persistente con signos o síntomas de shock) (1) .La mortalidad intrahospitalaria del paciente con TEP agudo sin datos de inestabilidad hemodinámica pasa de 8.1-14.7% a valores de 25-52.4% al evidenciarse alguno de los criterios contemplados en la definición de embolismo masivo (1)(2)(3) .Un embolismo pulmonar agudo sin hipotensión sistémica (presión arterial sistólica >90 mmHg) pero con datos de disfunción ventricular derecha o necrosis miocárdica establece el diagnóstico de TEP submasivo (1) . La necrosis miocárdica se manifiesta por la elevación de troponina I (>0.4 ng/ml) o troponina T (>0.1 ng/ml); mientras que la disfunción ventricular derecha se determina al documentarse al menos 1 de los siguientes criterios (1) :• Ecocardiograma con dilatación ventricular derecha (diámetro 4 cámaras apical entre el diámetro ventricular izquierdo >0.9) o disfunción sistólica.• Tomografía axial con dilatación ventricular derecha (diámetro 4 cámaras apical entre el diámetro ventricular izquierdo >0.9).• Elevación de péptido natriurético cerebral (BNP) (>90 pg/ml).• Elevación del N-terminal pro-BNP (>500 pg/ml).• Electrocardiograma con bloqueo de rama derecha de novo; elevación o depresión anteroseptal del segmento ST; o inversión de la onda T anteroseptal.Por otro lado, los pacientes con TEP agudo normotensos y sin datos de disfunción ventricular derecha y/o necrosis miocárdica se pueden definir como embolismo pulmonar de bajo riesgo y con pronóstico mejor que los dos grupos anteriores (1) . Trombosis venosa. FisiopatologíaEl concepto de trombosis venosa (TV) nace como eje fundamental del fenómeno fisiopatológico del embolismo pulmonar a partir de los postulados de Rudolf Virchow en 1856, quien establece que el daño a la pared del vaso sanguíneo, la alteración del flujo sanguíneo y un e...

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Diagnostic Strategies for Excluding Pulmonary Embolism in Clinical Outcome Studies

Cited by 195 publications

References 79 publications

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

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

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

Tema 6-2015: Tromboembolismo Pulmonar: Fisiopatología Y Diagnóstico

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