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Semin Vasc Med 2002; 02(4): 345-352
DOI: 10.1055/s-2002-36764
EDITORIAL

Copyright © 2002 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel.: +1(212) 584-4662

The Rehabilitation of Clinical Assessment for the Diagnosis of Pulmonary Embolism

Jan Jacques Michiels1 , Ari  Berghout3 , Wilfried Schroyens1 , Wilfried De Backer2 , Henk Hoogsteden4 , Peter M.T. Pattynama5
  • 1Hemostasis Thrombosis, Department of Hematology, University Hospital, Antwerp, Belgium
  • 2Department of Pulmonary Diseases, University Hospital, Antwerp, Belgium
  • 3Department of Internal Medicine, Medical Center, Rotterdam South
  • 4Department of Pulmonary Diseases, Academic Hospital Dijkzigt, Erasmus University medical Center, Rotterdam, The Netherlands
  • 5Department of Radiology, Academic Hospital Dijkzigt, Erasmus University Medical Center, Rotterdam, The Netherlands
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Publication History

Publication Date:
22 January 2003 (online)

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ABSTRACT

Pulmonary angiography is the gold standard for diagnosis of segmental pulmonary embolism, but no longer for subsegmental pulmonary embolism because the inter-observer agreement for angiographically documented subsegmental pulmonary embolism is only 60%. A normal rapid ELISA VIDAS D-dimer test result and a normal perfusion scan exclude pulmonary embolism with a negative predictive value of >99%, irrespective of clinical score.

The positive predictive value for pulmonary embolism of a high probability VP-scan compared to pulmonary angiography is 87% indicating that 13% of patients with a high probability VP-scan do not have pulmonary embolism. The combination of a negative CUS, a low clinical score, and a non-diagnostic VP-scan safely excludes pulmonary embolism. Patients with a non-diagnostic VP-scan, a negative CUS, but a moderate to high clinical score are candidates for pulmonary angiography.

The positive predictive value of helical spiral CT is >95 to 99%. The combination of a negative CUS, a low clinical score, and the presence of a clear alternative diagnosis is predicted to safely exclude pulmonary embolism. Helical spiral CT detects all clinical relevant pulmonary emboli and a large number of alternative diagnoses in symptomatic patients with a non-diagnostic or a high-probability VP-scan. The negative predictive value during 3 months followup after a negative spiral CT for pulmonary embolism in 4 retrospective studies and 1 prospective management study was >99%. Only a small group of patients (1-2%) with a non-diagnostic spiral CT are candidates for pulmonary angiography. Therefore, it is predicted that the spiral CT will replace both VP-scanning and pulmonary angiography to safely exclude or diagnose pulmonary emboli in patients with suspected pulmonary embolism.

KEYWORD

Pulmonary embolism - deep vein thrombosis - venous thromboembolism - ventilation perfusion scan - spiral CT - ELISA D-dimer test - clinical score assessment

REFERENCES

  • 1 Oudkerk M, van Beek J E, van Putten L W, Büller H R. Cost-effectiveness analysis of various strategies in the diagnostic management of pulmonary embolism.  Arch Intern Med . 1993;  153 947-954
    CrossrefPubMedSearch in Google Scholar
  • 2 Michiels J J. Rational diagnosis of pulmonary embolism (RADIA PE) in symptomatic outpatients with suspected PE: an improved strategy to exclude or diagnose venous thromboembolism by the sequential use of a clinical model, rapid ELISA D-dimer test, perfusion lung scan, ultrasonography, spiral CT and pulmonary angiography.  Semin Thromb Hemostas . 1998;  24 413-418
    PubMedSearch in Google Scholar
  • 3 The PIOPED Investigators. Value of the ventilation/perfusion scan in acute pulmonary embolism.  JAMA . 1990;  263 2753-2759
    Search in Google Scholar
  • 4 Hull R D, Raskob G E, Coates G, Panju A A. Clinical validity of a normal perfusion lung scan in patients with suspected pulmonary embolism.  Chest . 1990;  97 23-26
    CrossrefPubMedSearch in Google Scholar
  • 5 van Beek J E, Kuyer P M, Schenk B E. Normal perfusion lung scan in patients with clinically suspected pulmonary embolism: frequency and clinical validity.  Chest . 1995;  108 170-173
    CrossrefPubMedSearch in Google Scholar
  • 6 Berghout A, Oudkerk M, Hicks S G. Active implementation of a consensus strategy improves diagnosis and management in suspected pulmonary embolism.  Q J Med . 2000;  93 335-34
    CrossrefPubMedSearch in Google Scholar
  • 7 Wells P hS, Ginsberg J S, Anderson D R. Use of a clinical model for safe management of patients with suspected pulmonary embolism.  Ann Intern Med . 1998;  129 997-1005
    Search in Google Scholar
  • 8 Michiels J J, Pattynama P MT. Exclusion and diagnosis of pulmonary embolism by the rapid ELISA D-dimer test and non-invasive imaging techniques within the context of a clinical model.  Clin Appl Thrombosis/Hemostasis . 2000;  6 46-52
    PubMedSearch in Google Scholar
  • 9 Van Rossum B A, Van Houwelingen C H, Kieft G J. Prevalence of deep vein thrombosis in suspected and proven pulmonary embolism: a meta-analysis.  Br J Radiol . 1998;  71 1260-1265
    PubMedSearch in Google Scholar
  • 10 Hoellerich V L, Wigton R S. Diagnosing pulmonary embolism using clinical findings.  Arch Intern Med . 1986;  146 1699-1704
    CrossrefPubMedSearch in Google Scholar
  • 11 Celi A, Palla A, Petruzzelli S. Prospective study of a standardized questionnaire to improve clinical estimate of pulmonary embolism.  Chest . 1989;  95 332-337
    PubMedSearch in Google Scholar
  • 12 Sanson B J, Lijmer J G, MacGilevry M R. Comparison of a clinical probability estimate and two clinical models in patients with suspected pulmonary embolism.  Thromb Haemostas . 2000;  83 199-203
    PubMedSearch in Google Scholar
  • 13 Wells P S, Anderson D R, Rodger M. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and a D-dimer.  Ann Intern Med . 2001;  135 98-107
    Search in Google Scholar
  • 14 Perrier A, Desmarais S, Miron M J. Non-invasive diagnosis of venous thromboembolism in outpatients.  Lancet . 1999;  353 190-195
    Search in Google Scholar
  • 15 Perrier A. Pulmonary embolism: from clinical presentation to clinical probability assessment.  Semin Vasc Med . 2001;  2 147-154
    PubMedSearch in Google Scholar
  • 16 Wicki J, Perneger T V, Junod A I, Bounameaux H, Perrier A. Assessing clinical probability of pulmonary embolism in the emergency ward.  Arch Intern Med . 2001;  161 92-97
    CrossrefPubMedSearch in Google Scholar
  • 17 Diffin D C, Leyendecker J R, Johnson S P. Effect of anatomic distribution of pulmonary emboli on inter-observer agreement in the interpretation of pulmonary angiography.  AJR Am J Roentgenol . 1998;  171 1085-1089
    CrossrefPubMedSearch in Google Scholar
  • 18 Michiels J J, Perrier A, Bounameaux H. Should a normal D-dimer rule out angiographic pulmonary embolism or unfavourable outcome in patients left untreated?.  Thromb Haemostas . 2001;  85 753
    PubMedSearch in Google Scholar
  • 19 de Moerloose P h, Desmarais S, Bounameaux H. Contribution of a new rapid, individual and quantitative automated Vidas D-Dimer ELISA to exclude pulmonary embolism.  Thromb Haemostas . 1996;  75 11-13
    PubMedSearch in Google Scholar
  • 20 Pattynama P MT, Kuiper J W. Second-generation subsecond multislice computed-tomography: advancing the role of helical CT pulmonary angiography in suspected pulmonary embolism.  Semin Vasc Med . 2001;  1 195-203
    PubMedSearch in Google Scholar
  • 21 Van Rossum B A, Treurniet F EE, Kieft G J. Role of spiral CT volumetric computed tomography scanning in the assessment of patients with clinical suspicion of pulmonary embolism and abnormal ventilation/perfusion scan.  Thorax . 1996;  51 23-28
    PubMedSearch in Google Scholar
  • 22 Van Rossum B A, Pattynama P M, Ton E R. Spiral CT angiography for pulmonary embolism: Validation in 149 patients.  Radiology . 1996;  201 467-470
    PubMedSearch in Google Scholar
  • 23 Ferreti G R, Bosson J-L, Buffaz P-D. Acute pulmonary embolism: role of helical CT in 164 patients with intermediate probability at ventilation-perfusion scintigraphy and normal results at duplex of the legs.  Radiology . 1997;  205 453-458
    PubMedSearch in Google Scholar
  • 24 Ost D, Rozenshstein A, Saffran L. The negative predictive value of spiral computed tomography for the diagnosis of pulmonary embolism in patients with nondiagnostic ventilation-oerusion scans.  Am J Med . 2001;  110 16-21
    CrossrefPubMedSearch in Google Scholar
  • 25 Garg K, Sieler H, Welsh C H. Clinical validity of helical CT being interpreted as negative for pulmonary embolism.  Implications for patient treatment. AJR Am J Roentgenol . 1999;  172 1627-1631
    PubMedSearch in Google Scholar
  • 26 Lomis N N, Yoon H C, Moran A G, Miller F J. Clinical outcomes of patients after a negative spiral CT pulmonary angiogram in the evaluation of acute pulmonary embolism.  J Vasc Interv Radio . 1999;  10 707-712
    PubMedSearch in Google Scholar
  • 27 Goodman L R, Lipchik R J, Kuzo R S. Subsequent pulmonary embolism: risk after a negative helical CT pulmonary angiogram. Prospective comparison with scintigraphy.  Radiology . 2000;  215 535-542
    PubMedSearch in Google Scholar
  • 28 Göttsäter A, Berg A, Centegard J. Clinically suspected pulmonary embolism: is it safe to withhold anticoagulation after a negative spiral CT?.  Eur Radiol . 2001;  11 65-72
    CrossrefPubMedSearch in Google Scholar
  • 29 Van Strijen J L M, de Monyé W, Schiereck J. Helical CT as the primary diagnostic test in suspected pulmonary embolism: prospective ANTELOPEW multicenter trial in 512 patients. Radiology .  2001;  221(P) 255
    PubMedSearch in Google Scholar