Multidetector-row computed tomography in suspected pulmonary embolism

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Summary. Introduction: The diagnostic value of clinical presentation of pulmonary embolism (PE) is uncertain in the elderly, who often have concomitant cardiopulmonary diseases that may mimic PE. The aim of our study was to assess the differential value of risk factors, symptoms and clinical signs of venous thromboembolism, results of electrocardiogram and chest X‐ray for the diagnosis of PE in suspected patients according to age. Methods: We analyzed data from two outcome studies which enrolled 1721 consecutive patients presenting in the emergency department with clinically suspected PE defined as acute onset of new or worsening shortness of breath or chest pain without any other obvious etiology. All patients underwent a sequential diagnostic work‐up and a 3‐month follow‐up. Results: The proportion of confirmed PE was 24.2% (416 of 1721). Strength of the association with PE did not differ according to age group for history of venous thromboembolism (VTE), recent surgery, tachypnea at admission or right ventricular strain on electrocardiogram. Active malignancy, hemoptysis, tachycardia, hemidiaphragmatic elevation and pleural effusion at chest X‐ray were no more associated with PE in the patients aged of 75 years or more. Finally, symptoms and signs of deep venous thrombosis, and an alternative diagnosis less probable than PE were associated with PE in all age groups, but the strength of this association decreased significantly with advancing age. Conclusion: Some risk factors, symptoms and signs of VTE are less strongly or even not at all associated with PE in the elderly. Physicians should take this into account when attending elderly patients suspected of PE and when assessing their clinical probability of PE.

Section: Patientsmentioning

confidence: 99%

Differential value of risk factors and clinical signs for diagnosing pulmonary embolism according to age

Gal

Righini²,

Roy³

et al. 2005

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“…First-generation single-slice spiral CT had a low sensitivity (about 70%) for PE [4,5], and had to be used in conjunction with lower limb vein US to safely rule out the diagnosis of PE. At least two studies demonstrated that, owing to its improved sensitivity, multislice CT (MSCT) could be used without addition of US [1,2]. This was definitely confirmed in a recently published multicenter randomized non-inferiority trial [4] including 1819 patients with suspected PE, which compared head to head the following diagnostic strategies: (i) DD-US-CT; and (ii) DD-CT.…”

Section: Introductionmentioning

confidence: 97%

“…The contemporary diagnostic approach to pulmonary embolism (PE) is based on the combination of clinical probability assessment with sequential diagnostic tests such as plasma Ddimer measurement (DD), lower limb venous compression ultrasonography (US) and helical computed tomography (CT) [1][2][3]. First-generation single-slice spiral CT had a low sensitivity (about 70%) for PE [4,5], and had to be used in conjunction with lower limb vein US to safely rule out the diagnosis of PE.…”

Section: Introductionmentioning

confidence: 99%

Complete venous ultrasound in outpatients with suspected pulmonary embolism

Righini¹,

Gal²,

Aujesky³

et al. 2009

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Summary. Background: Compression ultrasonography (US) confined to the proximal veins is usually performed to detect deep vein thrombosis (DVT) in patients with suspected pulmonary embolism (PE). Recent studies suggested a limited yield of proximal US when multislice computed tomography (MSCT) was used. Objectives: To assess whether performing an additional distal vein US would increase the diagnostic yield of the test. Patients and methods: Data of 855 consecutive outpatients included in a multicenter randomized controlled trial were analyzed. Patients were investigated by a sequential diagnostic strategy including clinical probability assessment, Ddimer measurement, proximal US and MSCT. Proximal US was completed by an examination of the distal veins, the result of which was not disclosed to the physician in charge of the patient. Results: US was positive in 21% of patients, of whom 10% (53/541) had proximal DVT and 11% (59/541) isolated distal DVT. Of the 59 patients with distal DVT, 21 (36%) had no PE on MSCT. Twenty of those 21 patients were not given anticoagulant therapy and had an uneventful follow-up. The diagnostic performance of distal US for the diagnosis of PE was as follows: sensitivity 22% [95% confidence interval (CI) 17-29]; specificity 94% (95% CI 91-96); positive likelihood ratio 3.9 (95% CI 2.4-6.4). Conclusions: In patients with suspected PE, distal US has limited diagnostic performance, and its additional use only modestly increases the yield of US. Moreover, it carries a high false-positive rate, impeding the use of distal US as a confirmatory test for PE.

“…In the remaining patients, a negative CTPA has a 3-month incidence of subsequent venous thrombosis of 1.2% (95% CI, 0.8-1.8) with a very low VTE-related mortality risk (0.6%; 95% CI, 0.4-1.1) [62]. The yield of additional CUS in patients with normal multi-row detector CTPA is very low (0.9-1.4%) and therefore unnecessary [63,88]. Using this algorithm, CT scanning can be avoided in 30% of patients with suspected acute PE and a management decision can be made in 98% of patients.…”

Section: Diagnostic Algorithms For Clinically Suspected Pementioning

confidence: 99%

Diagnostic management of acute deep vein thrombosis and pulmonary embolism

Huisman

Klok

2013

145

128

To cite this article: Huisman MV, Klok FA. Diagnostic management of acute deep vein thrombosis and pulmonary embolism. J Thromb Haemost 2013; 11: 412-22.Summary. Acute deep vein thrombosis (DVT) and pulmonary embolism (PE) represent two expressions of a similar clinical pathological process, often referred to as venous throm-boembolism (VTE). It has long been recognized that, as clinical signs and symptoms of PE and DVT are not specific for the diagnosis, objective diagnosis in both patients presenting with leg symptoms and those with chest symptoms is mandatory. Since the last review on this subject in this journal in 2009, several large trials have been performed that shed new light on all aspects of the diagnostic management of suspected VTE, especially in the field of simplified clinical decision rules, agedependent D-dimer cut-offs and magnetic resonance imaging. A literature search covering the period 2007-2012 was performed using the Medline/PubMed database to identify all relevant papers regarding the diagnostic management of acute PE and DVT. Established concepts and the latest evidence on this subject will be the main focus of this review.Keywords: clinical decision rule, D-dimer, deep vein thrombosis, diagnostic management, imaging, pulmonary embolism, venous thromboembolism. Clinical probability assessment and D-dimer testsA certain diagnosis of acute PE or DVT can only be established by means of imaging [1]. On the other hand, ruling out acute VTE can be safely achieved by using a standardized clinical probability assessment and a D-Dimer blood test. The main advantage of such an approach is a reduction in the required number of imaging tests, which are in general time consuming, costly and associated with radiation exposure and other complications. D-dimerFibrin D-dimer is the final product of the plasmin-mediated degradation of cross-linked fibrin. Its plasma concentration is dependent on fibrin generation and subsequent degradation by the endogenous fibrinolytic system [2]. Ddimer levels are typically elevated in patients with acute venous thrombosis. Accordingly, the sensitivity of an elevated D-dimer concentration for VTE is very high [3]. In contrast, as D-dimer levels can be elevated in other clinical conditions that are associated with enhanced fibrin (e.g. malignancy, trauma, increased age, disseminated intravascular coagulation, inflammation, infection, sepsis, postoperative states and pre-eclampsia), the specificity for acute thrombosis is rather poor [3]. Thus the diagnostic strength of D-dimer tests lies in ruling out DVT or PE.A large variety of assays are available for D-dimer measurement, and they are all based on the use of monoclonal antibodies that recognize epitopes of the D-dimer fragment that are not present on fibrinogen or noncrossed fragments of fibrin [4]. From numerous accuracy and management studies, it has been demonstrated that the sensitivities of the D-dimer enzyme-linked immunofluorescence assay (ELFA) (DVT 96%; PE 97%), microplate enzyme-linked immunosorbent assay (...