Single-Detector Helical Computed Tomography as the Primary Diagnostic Test in Suspected Pulmonary Embolism: A Multicenter Clinical Management Study of 510 Patients

Strijen, M.J.L. van; Mony, Wouter de; Schiereck, Jan; Kieft, G. J.; Prins, Martin H.; Huisman, Menno V.; Pattynama, Peter M. T.

doi:10.7326/0003-4819-138-4-200302180-00009

Cited by 217 publications

(157 citation statements)

References 31 publications

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“…Surprisingly, European physicians seem to have a better yield in diagnosing PE since their positive CTPA rate is 2–3 times higher than that of the US. This can be explained partly by the fact that CTPAs are more accessible to US physicians and may also reflect the fact that European physicians adhere to the guidelines more than their US counterparts [15,16]. …”

Section: Discussionmentioning

confidence: 99%

Computed tomography pulmonary angiography is overused to diagnose pulmonary embolism in the emergency department of academic community hospital

Osman

Subedi

Ahmed

et al. 2018

Journal of Community Hospital Internal Medicine Perspectives

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Background: Pulmonary embolism (PE) is a common disease in the USA responsible for up to 10% of hospital mortality. Modified wells score (MWS) and D-dimer assay are used to categorize patients into high or low probability of PE. Patient with high probability need Computed tomography pulmonary angiography (CTPA), while patients with low probability and low D-dimer can safely forgo the CTPA. Objectives: The aim of this study was to investigate the rate of inappropriate CTPA use in the emergency department of a community teaching hospital. Methods: A retrospective chart review of adult patients who underwent CTPA for suspected PE in the emergency department for 2015 was done. CTPA use was considered inappropriate if MWS was less than or equal to 4 and D-dimer was either not ordered or its value was less than 500 μg/L. Bivariate analysis with Fisher’s exact tests and Student’s t-tests as well as multivariate logistic regression analysis were done to examine relationship between study explanatory variables and study outcome. Results: 295 patients were included in the study. The mean age was 51.2(±14.5) years, 68.8% were females. The prevalence of PE was 5.4% and 41% of the CTPAs -were inappropriately ordered. Males were twice (OR 2.1; 95% CI 1.2, 3.6) as likely as females to have an inappropriately ordered CTPA after controlling for a high MWS, age, and tobacco history. Conclusion: CTPA is overused to diagnose PE in the emergency department. Quality improvement projects are needed to encourage physicians to adhere to the current guidelines.

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Section: Discussionmentioning

confidence: 99%

Computed tomography pulmonary angiography is overused to diagnose pulmonary embolism in the emergency department of academic community hospital

Osman

Subedi

Ahmed

et al. 2018

Journal of Community Hospital Internal Medicine Perspectives

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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%

“…CTPA is safe and rapid and offers the advantage of revealing ancillary lung findings that may be clinically significant. 12 Although the test is an important addition to a clinician's diagnostic armamentarium, Bayesian analysis must be used to interpret its results, especially when CTPA is used as the first-line diagnostic test. Our data raise the troubling concern that reliance on CTPA as the sole diagnostic test for suspected pulmonary embolism may result in a large number of patients with false-positive CT scans receiving anticoagulation treatment.…”

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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“…Three studies have concluded that withholding anticoagulant therapy on the basis of a negative helical CT scan is safe [100,102,103]. Swensen et al [99] and Donato et al [102] found that only 8 of 993 and 4 of 239 patients developed VTE within 3 months of a negative CT scan.…”

Section: Spiral Computed Tomographymentioning

confidence: 99%

Pulmonary embolism: an unsuspected killer

Laack

Goyal

2004

Emergency Medicine Clinics of North America

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Single-Detector Helical Computed Tomography as the Primary Diagnostic Test in Suspected Pulmonary Embolism: A Multicenter Clinical Management Study of 510 Patients

Abstract: In patients with suspected PE, helical CT can be used safely as the primary diagnostic test to rule out PE. Serial compression ultrasonography has limited additional value.

Cited by 217 publications

References 31 publications

Computed tomography pulmonary angiography is overused to diagnose pulmonary embolism in the emergency department of academic community hospital

Computed tomography pulmonary angiography is overused to diagnose pulmonary embolism in the emergency department of academic community hospital

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

Pulmonary embolism: an unsuspected killer

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