CC BY 4.0 · TH Open 2019; 03(01): e22-e27
DOI: 10.1055/s-0038-1676812
Original Article
Georg Thieme Verlag KG Stuttgart · New York

Chest X-Ray Not Routinely Indicated Prior to the YEARS Algorithm in the Diagnostic Management of Suspected Pulmonary Embolism

Liselotte M. van der Pol
1   Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
2   Department of Internal Medicine, Haga Teaching Hospital, The Hague, The Netherlands
,
Cecile Tromeur
1   Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
3   Groupe d'Etude de la Thrombose de Bretagne Occidentale, Department of Internal Medicine and Chest Diseases, University of Brest, CHRU Brest, Brest, France
,
Laura M. Faber
4   Department of Internal Medicine, Red Cross Hospital, Beverwijk, The Netherlands
,
Tom van der Hulle
1   Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
,
Lucia J. M. Kroft
5   Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
,
Albert T. A. Mairuhu
2   Department of Internal Medicine, Haga Teaching Hospital, The Hague, The Netherlands
,
Albert de Roos
5   Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
,
Menno V. Huisman
1   Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
,
Frederikus A. Klok
1   Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
› Author Affiliations
Further Information

Publication History

22 June 2018

26 October 2018

Publication Date:
08 January 2019 (online)

Abstract

Background The YEARS algorithm was designed to simplify the diagnostic process of suspected pulmonary embolism (PE) and to reduce the number of required computed tomography pulmonary angiography (CTPA) scans. Chest X-ray (CXR) is often used as initial imaging test in patients suspected for PE.

Aim To determine if CXR results differ between patients with confirmed PE and with PE ruled out, and to investigate whether CXR provides incremental diagnostic value to the YEARS criteria that is used for selecting patients with CTPA indication.

Methods This post-hoc analysis concerned 1,473 consecutive patients with suspected PE who were managed according to YEARS and were subjected to CXR as part of routine care. The prevalence and likelihood ratios of seven main CXR findings for a final diagnosis of PE were calculated.

Results A total of 214 patients were diagnosed with PE at baseline (15%). Abnormal CXR occurred more often in patients with confirmed PE (36%, 77/214) than in patients without PE (26%; 327/1,259), for an odds ratio of 1.60 (95% confidence interval: 1.18–2.18). Only the unexpected finding of a (rib)fracture or pneumothorax, present in as few as six patients (0.4%), significantly lowered the post-test probability of PE to an extent that CTPA could have been avoided.

Conclusion The incremental diagnostic value of CXR to the YEARS algorithm to rule out PE was limited. CXR was more frequently abnormal in patients with PE than in those in whom PE was ruled out. These data do not support to perform CXR routinely in all patients with suspected PE, prior to CTPA imaging.

Authors' Contributions

L.M.v.d.P. and F.A.K. had full access to all data in the study and take the responsibility for the integrity of the data and the accuracy of the data analysis.


Acquisition of the data: L.M.v.d.P., L.M.F., T.v.d.H., A.T.A.M., M.V.H., F.A.K.


Analysis and interpretation of the data: L.M.v.d.P., C.T., F.A.K.


Image acquisition: L.J.M.K., A.d.R.


Drafting of the manuscript: L.M.v.d.P., C.T., F.A.K.


Critical revision of the manuscript: L.M.v.d.P., C.T., L.M.F., T.v.d.H., L.J.M.K., A.T.A.M., A.d.R., M.V.H., F.A.K.


Final approval of the manuscript: L.M.v.d.P., C.T., L.M.F., T.v.d.H., L.J.M.K., A.T.A.M., A.d.R., M.V.H., F.A.K.


 
  • References

  • 1 Konstantinides SV. 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J 2014; 35 (45) 3145-3146
  • 2 Raja AS, Greenberg JO, Qaseem A, Denberg TD, Fitterman N, Schuur JD. ; Clinical Guidelines Committee of the American College of Physicians. Evaluation of patients with suspected acute pulmonary embolism: Best Practice Advice from the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med 2015; 163 (09) 701-711
  • 3 Huisman MV, Klok FA. How I diagnose acute pulmonary embolism. Blood 2013; 121 (22) 4443-4448
  • 4 Righini M, Van Es J, Den Exter PL. , et al. Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism: the ADJUST-PE study. JAMA 2014; 311 (11) 1117-1124
  • 5 van der Hulle T, Cheung WY, Kooij S. , et al; YEARS Study Group. Simplified diagnostic management of suspected pulmonary embolism (the YEARS study): a prospective, multicentre, cohort study. Lancet 2017; 390 (10091): 289-297
  • 6 Zubairi AB, Husain SJ, Irfan M, Fatima K, Zubairi MA, Islam M. Chest radiographs in acute pulmonary embolism. J Ayub Med Coll Abbottabad 2007; 19 (01) 29-31
  • 7 Worsley DF, Alavi A, Aronchick JM, Chen JT, Greenspan RH, Ravin CE. Chest radiographic findings in patients with acute pulmonary embolism: observations from the PIOPED Study. Radiology 1993; 189 (01) 133-136
  • 8 Bergus GR, Barloon TS, Kahn D. An approach to diagnostic imaging of suspected pulmonary embolism. Am Fam Physician 1996; 53 (04) 1259-1266
  • 9 Coche E, Verschuren F, Hainaut P, Goncette L. Pulmonary embolism findings on chest radiographs and multislice spiral CT. Eur Radiol 2004; 14 (07) 1241-1248
  • 10 Elliott CG, Goldhaber SZ, Visani L, DeRosa M. Chest radiographs in acute pulmonary embolism. Results from the International Cooperative Pulmonary Embolism Registry. Chest 2000; 118 (01) 33-38
  • 11 Robin P, Le Roux PY, Tissot V. , et al. Interest of chest X-ray in tailoring the diagnostic strategy in patients with suspected pulmonary embolism. Blood Coagul Fibrinolysis 2015; 26 (06) 643-648
  • 12 Srivastava SD, Eagleton MJ, Greenfield LJ. Diagnosis of pulmonary embolism with various imaging modalities. Semin Vasc Surg 2004; 17 (02) 173-180
  • 13 National Clinical Guideline Centre (UK). Venous thromboembolic diseases: the management of venous thromboembolic diseases and the role of thrombophilia testing. London: Royal College of Physicians (UK); June 2012
  • 14 Cardinale L, Volpicelli G, Lamorte A, Martino J, Veltri A. Revisiting signs, strengths and weaknesses of standard chest radiography in patients of acute dyspnea in the emergency department. J Thorac Dis 2012; 4 (04) 398-407