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

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.

Keywords

pulmonary embolism - diagnosis - chest X-ray - clinical decision rule - D-dimer

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.

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