When to perform CTA in patients suspected of PE?

Ghaye, Benoît; Dondelinger, Robert

doi:10.1007/s00330-007-0768-x

Cited by 9 publications

(3 citation statements)

References 85 publications

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“…A spiral CT scan is currently the test of choice in the diagnosis of PE, replacing V/Q scanning, 9,23,24 which is consistent with current practice at this institution. In this study, a majority of emergency room patients who presented with pleuritic chest pain or shortness of breath and underwent a spiral CT scan had normal examinations, similar to the majority of outpatients that were found to have normal or very low clinical probability of PE by V/Q scanning.…”

Section: Diagnostic Procedures Of Pesupporting

confidence: 55%

The Current State of Practice in the Diagnosis of Venous Thromboembolism at an Academic Medical Center

Lee

Zierler

2010

Vasc Endovascular Surg

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Evidence-based guidelines for the diagnosis of venous thromboembolism (VTE) have been recommended, yet the adoption of such guidelines into daily practice is unknown. The purpose of this study was to describe the current practices in the diagnosis of VTE. Medical records of 1161 adult patients who underwent lower extremity venous duplex scans (VDS), chest computerized tomographic (CT) angiography, or ventilation and perfusion (V/Q) scans during a 6-month period were retrospectively reviewed in an academic medical center. Patients who were first diagnosed by CT or V/Q scan still underwent a VDS. Nine patients at high risk had incomplete CT scans, yet no further tests were performed. Five pregnant patients had CT scans as the initial test instead of being screened with VDS or V/Q scanning. Inappropriate use of imaging tests was documented. The recommended guidelines of using clinical probability and D-dimer as the initial screening tests for VTE diagnosis were underused.

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Section: Diagnostic Procedures Of Pesupporting

confidence: 55%

The Current State of Practice in the Diagnosis of Venous Thromboembolism at an Academic Medical Center

Lee

Zierler

2010

Vasc Endovascular Surg

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“…Overuse of CTPA in diagnosing PTE is not cost-benefit, exposing the patients to false-positive test results, contrast induced nephropathy, and carcinogenic radiation exposure. It is possible to avoid unnecessary imaging requests by more adherence to PIOPED II investigators recommendation ( 11 ). This could be achieved with wiser and more accurate clinical risk assessment by more experienced clinicians in the thromboembolic field, especially in the setting of educational hospitals in which the decisions of less trained physicians are influenced by unwarranted fears of disease outcome.…”

Section: Discussionmentioning

confidence: 99%

Computed Tomography Pulmonary Angiography for Evaluation of Patients with Suspected Pulmonary Embolism: Use or Overuse

et al. 2015

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Background:The use of computed tomography pulmonary angiography (CTPA) has been increased during the last decade.Objectives:We studied the adherence to current diagnostic recommendations for evaluation of pulmonary embolism in a teaching hospital of Tehran University of Medical Sciences.Patients and Methods:The registered medical records (Wells scores and serum D-dimer level) of all patients whose CTPA was performed with suspicion of pulmonary thromboembolism (PTE) were studied retrospectively. Modified Wells score of each patient was determined without being aware of the CTPA results. The patients were categorized to those with a high (likely) clinical probability (score > 4) and low (unlikely) clinical probability (score≤ 4) of PTE.Results:During a 6-month period, 82 patients who underwent CTPA were included. The prevalence of PTE was 62.2% in the group of subjects with a likely clinical risk. In 45 (54.8%) of those patients whose CTPA was requested, the PTE was unlikely based on modified Wells criteria. In the clinically unlikely group, serum D-dimer assay was done in 15 out of 45 (33.3%), while it was inappropriately checked in 10 out of 37 (27.0%) with a clinically likely risk. General adherence rate to diagnostic algorithm of PTE was 43.9%.Conclusion:There is still excessive unjustified concern of PTE in less trained physicians leading to excessive diagnostic work-up. Loyalty to the existing guideline for management of suspected PTE in educational hospitals and supervision of attending physicians could prevent overuse of CTPA.

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“…However, increased CTPA examinations are associated with cost implications and increasing ionising radiation burden [7]. Patients referred for diagnostic work-up must be carefully selected to avoid unnecessary radiation and expenditure and to yield the desired prevalence of 25% or greater.…”

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confidence: 99%

Pulmonary embolism: investigation of the clinically assessed intermediate risk subgroup

Warren¹,

Matthews²

2012

BJR

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Objectives: The simplified Wells pre-test probability scoring algorithm for preinvestigation evaluation of pulmonary emboli (PE) is a commonly utilised and validated assessment tool. We sought to identify whether use of a dichotomised scoring system altered the overall negative predictive value (NPV) in patients referred for CT pulmonary angiography (CTPA) assessment of suspected PE. Methods: Prospective data collection of all patients referred for CTPA evaluation of suspected acute PE during a 3 year period was carried out. Pre-test risk stratification was performed according to simplified Wells criteria in conjunction with plasma D-Dimer (BioPool and IL test) estimation. Retrospective dichotomisation was also performed. Results: 2531 patients were investigated for suspected acute PE; acute thromboemboli were confirmed in 22.7%. The overall NPV for negative D-Dimer and intermediate pre-test probability (PTP) was 98.9% [95% confidence interval (CI) 96.3-99.7%]; with retrospective dichotomisation, the NPV for the PE unlikely group was 99.0% (95% CI 94.8-99.8%). Implementation of dichotomised scoring, excluding PE unlikely with negative D-Dimer cases from further imaging, would have yielded a 4% reduction in CTPA referral pathway imaging at our institution. Conclusion: We demonstrate no significant difference between exclusion in the intermediate subgroup and the retrospectively dichotomised PE unlikely group and demonstrate the high negative predictive power of the Bio-Pool and IL tests in conjunction with the Wells PTP tool. Prior to implementation of new guidelines for exclusion of patients with suspected PE from further imaging, hospitals should audit their own practice and validate the D-Dimer assay utilised at their institution.

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When to perform CTA in patients suspected of PE?

Cited by 9 publications

References 85 publications

The Current State of Practice in the Diagnosis of Venous Thromboembolism at an Academic Medical Center

The Current State of Practice in the Diagnosis of Venous Thromboembolism at an Academic Medical Center

Computed Tomography Pulmonary Angiography for Evaluation of Patients with Suspected Pulmonary Embolism: Use or Overuse

Pulmonary embolism: investigation of the clinically assessed intermediate risk subgroup

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