The Rehabilitation of Clinical Assessment for the Diagnosis of Pulmonary Embolism

Jan Jacques Michiels; Ari Berghout; Wilfried Schroyens; Wilfried De Backer; Henk Hoogsteden; Peter M. T. Pattynama

doi:10.1055/s-2002-36764

Seminars in Vascular Medicine, Inhaltsverzeichnis

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

EDITORIAL

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

Abstract

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

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Referenzen

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