Multidetector-Row Computed Tomography in Suspected Pulmonary Embolism

Perrier, Arnaud; Roy, Preety Mittal; Sanchez, Olivier

doi:10.1016/j.accreview.2005.08.045

Cited by 75 publications

(118 citation statements)

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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%

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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%

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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“…11,15,18,[21][22][23][24][25][26][27][28][29][30][31][32][33][34][35] The three most widely used clinical decision rules are the simplified Wells score, the revised Geneva score, and the pulmonary embolism rule-out criteria (PERC) rule. The simplified Wells score comprises seven variables and has been derived and validated in the North American population.…”

Section: Discussionmentioning

confidence: 99%

“…The use of an oxygen saturation level in pulmonary embolism has been looked at in a recent study, showing that a pulse oximetry cut-off of 95% room air oxygen saturation at sea level can effectively differentiate patients with pulmonary embolism into highand low-risk groups. 33 Another study evaluated the benefit of a treadmill exercise oxygen saturation test, by way of respiratory gas exchange analysis to help diagnose pulmonary embolism in locations where immediate imaging is not available. 37 The authors concluded that exercise-induced desaturation might be sensitive and specific for diagnosing pulmonary embolism.…”

Section: Discussionmentioning

confidence: 99%

Ambulatory vital signs in the workup of pulmonary embolism using a standardized 3-minute walk test

Amin

Perry

Stiell

et al. 2015

CJEM

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Objective: Diagnosing pulmonary embolism can be difficult given its highly variable clinical presentation. Our objective was to determine whether a decrease in oxygen saturation or an increase in heart rate while ambulating could be used as an objective tool in the diagnosis of pulmonary embolism. Methods: This was a two-site tertiary-care-centre prospective cohort study that enrolled adult emergency department or thrombosis clinic patients with suspected or newly confirmed pulmonary embolism. Patients were asked to participate in a standardized 3-minute walk test, which assessed ambulatory heart rate and ambulatory oxygen saturation. The primary outcome was pulmonary embolism. Results: We enrolled 114 patients, including 30 with pulmonary embolism (26.3%). A ≥2% absolute decrease in ambulatory oxygen saturation and an ambulatory change in heart rate >10 beats per minute (BPM) were significantly associated with pulmonary embolism. An ambulatory heart rate change of >10 BPM had a sensitivity of 96.6% (95% confidence interval [CI] 83.3 to 99.4) and a specificity of 31.0% (95% CI 22.1 to 45.0) for pulmonary embolism. A ≥2% absolute decrease ambulatory oxygen saturation had a sensitivity of 80.2% (95% CI 62.7 to 90.5) and a specificity of 39.3% (95% CI 29.5 to 50.0) for pulmonary embolism. The combination of both variables yielded a sensitivity of 100.0% (95% CI 87.0 to 100.0) and a specificity of 11.0% (95% CI 6.6 to 21.0). Conclusion: In summary, our study found that an ambulatory heart rate change of >10 BPM or a ≥2% absolute decrease in ambulatory oxygen saturation from baseline during a standardized 3-minute walk test are highly correlated with pulmonary embolism. Although the findings appear promising, neither of these variables can currently be recommended as a screening tool for pulmonary embolism until larger prospective studies examine their performance either alone or with pre-existing rules. RÉSUMÉObjectif: L'embolie pulmonaire peut être difficile à diagnostiquer étant donné son tableau clinique très variable. L'étude visait à déterminer si une diminution du degré de saturation du sang en oxygène ou une augmentation de la fréquence cardiaque en cours de déambulation pouvait servir d'outil objectif de diagnostic de l'embolie pulmonaire. Méthode: Il s'agit d'une étude prospective de cohortes, menée dans deux centres hospitaliers de soins tertiaires, à laquelle ont participé des patients provenant d'un service d'urgence pour adultes et d'un centre de thrombose, chez qui était soupçonnée ou avait été confirmée depuis peu une embolie pulmonaire. L'on a demandé aux patients de participer à une épreuve de marche normalisée de 3 minutes au cours de laquelle étaient évalués la fréquence cardiaque et le degré de saturation du sang en oxygène, en mode ambulatoire. Le principal critère d'évaluation était l'embolie pulmonaire. Résultats: Ont participé à l'étude 114 patients, dont 30 souffraient d'une embolie pulmonaire (26,3 %). Une diminution absolue ≥2 % du degré de saturation du sang en oxygène en cours d...

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“…It is reported that a D-dimer value below the conventional cutoff (500 ng/ml) combined with clinical probability could rule out the PE in about 30% suspected patients (Perrier et al, 2005;van et al, 2006;Righini et al, 2008). The D-dimer value increases with age.…”

Section: Discussionmentioning

confidence: 99%

A New D-dimer Cutoff Value to Improve the Exclusion of Deep Vein Thrombosis in Cancer Patients

Chen¹,

Li²,

Liu³

et al. 2014

Asian Pacific Journal of Cancer Prevention

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Objective: To find a more appropriate alternative to D-dimer cutoff value for the diagnosis of deep vein thrombosis (DVT) in cancer patients. Methods: A total of 711 cancer patients with symptoms suspicious of DVT were included in the study. D-dimer levels were assessed using ELISA. All patients were subjected to imaging procedures. Results: Among 711 patients with cancer, 466 (65.5%) were females and 245 (34.5%) were males, with an average age of 57.3± 13.23 years. The mean age in the DVT group was significantly higher than in the non-DVT group (P<0.05). The D-dimer levels of the DVT group were significantly higher than those of the non-DVT group (P<0.05). The incidence rate of DVT varied significantly according to cancer type (P<0.05). Increasing age and lung cancer were significantly correlated with D-dimer levels (P<0.05), and a one-year increase in age was associated with a 14.28 ng/ml increase in the D-dimer value. The optimal cutoff point for D-dimer was found to be 981 ng/ml, with a sensitivity of 86.4%, specificity of 79.4%, and accuracy of 82.6%. If the D-dimer cutoff point was set to 981ng/ml, the specificity would increase from 61.8% to 85.5% without loss of sensitivity in patients aged 40 years or younger. In patients aged more than 40 years, the new cutoff almost doubled the specificity with slightly reduced sensitivity. Conclusion: In cancer patients, a new cutoff value of 981 ng/ml effectively improved the exclusion of DVT, especially for patients aged more than 40 years.

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Multidetector-Row Computed Tomography in Suspected Pulmonary Embolism

Cited by 75 publications

References 0 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

Ambulatory vital signs in the workup of pulmonary embolism using a standardized 3-minute walk test

A New D-dimer Cutoff Value to Improve the Exclusion of Deep Vein Thrombosis in Cancer Patients

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