Combination of Pulmonary Embolism Rule-out Criteria and YEARS Algorithm in a European Cohort of Patients with Suspected Pulmonary Embolism

2018 ◽  
Vol 118 (03) ◽  
pp. 547-552 ◽  
Author(s):  
L. van der Pol ◽  
T. van der Hulle ◽  
A. Mairuhu ◽  
M. Huisman ◽  
F. Klok
Keyword(s):  
Pulmonary Embolism ◽  
Failure Rate ◽  
Pulmonary Angiography ◽  
Absolute Difference ◽  
Diagnostic Strategy ◽  
Suspected Pulmonary Embolism ◽  
Computed Tomography Pulmonary Angiography ◽  
Modest Improvement ◽  
Rule Out

Background Both the YEARS algorithm and the pulmonary embolism (PE) rule-out criteria (PERC) were created to exclude PE with limited diagnostic tests. A diagnostic strategy combining both scores might save additional computed tomography pulmonary angiography (CTPA) scans, but they have never been evaluated in conjunction. Aim The aim of this study was to determine the safety and efficiency of combining YEARS and PERC in a single diagnostic strategy for suspected PE. Methods The PERC rule was assessed in 1,316 consecutive patients with suspected PE who were managed according to YEARS. We calculated the absolute difference (with 95% confidence interval [CI]) in failure rate and the number of ‘saved’ CTPAs for the scenario that PE would have been ruled out without CTPA in the absence of all PERC items. Results Using the YEARS algorithm, PE was diagnosed in 189 patients (14%), 680 patients (52%) were managed without CTPA and the 3-month rate of venous thromboembolism in patients in whom PE was ruled out was 0.44% (95% CI: 0.19–1.0). Only 6 of 154 patients (3.9%; 95% CI: 1.4–8.2) with no YEARS items who were referred for CTPA would have been PERC negative, of whom none were diagnosed with PE at baseline or during follow-up (0%; 95% CI: 0–64). Applying PERC before YEARS in all patients would have led to a failure rate of 1.42% (95% CI: 0.87–2.3%), 0.98% (95% CI: 0.17–1.9) more than shown in patients managed by YEARS. Conclusion Combining YEARS with PERC would have yielded only a modest improvement of efficiency in patients without a YEARS item and an unacceptable failure rate in patients with ≥ 1 YEARS item.

scholarly journals Diagnosis of acute Pulmonary Embolism

2018 ◽  
Vol 38 (01) ◽  
pp. 11-21 ◽  
Author(s):  
Helia Robert-Ebadi ◽  
Marc Righini
Keyword(s):  
Pulmonary Embolism ◽  
Cost Effective ◽  
Pulmonary Angiography ◽  
Suspected Pulmonary Embolism ◽  
Computed Tomography Pulmonary Angiography ◽  
Diagnostic Algorithms ◽  
Effective Diagnosis ◽  
Management Algorithms ◽  
Special Patient ◽  
D Dimer

SummaryDuring the last three decades, considerable advances in the management of patients with suspected pulmonary embolism (PE) have improved diagnostic accuracy and made management algorithms safer, easier to use and well standardized. These diagnostic algorithms are mainly based on the assessment of clinical pretest probability, D-Dimer measurement and imaging tests, mainly computed tomography pulmonary angiography (CTPA). These diagnostic algorithms allow a safe and cost-effective diagnosis for most patients with suspected PE.In this review, we discuss current existing evidence for PE diagnosis, the challenge of diagnosing PE in special patient populations, as well as novel imaging tests for PE diagnosis.

Is a normal computed tomography pulmonary angiography safe to rule out acute pulmonary embolism in patients with a likely clinical probability?

2017 ◽  
Vol 117 (08) ◽  
pp. 1622-1629 ◽  
Author(s):  
Tom van der Hulle ◽  
Nick van Es ◽  
Paul den Exter ◽  
Josien van Es ◽  
Inge Mos ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Pulmonary Embolism ◽  
Acute Pulmonary Embolism ◽  
Meta Analysis ◽  
Pulmonary Angiography ◽  
Computed Tomography Pulmonary Angiography ◽  
Clinical Probability ◽  
Pulmonary Angiogram ◽  
Wells Rule ◽  
Rule Out

SummaryA normal computed tomography pulmonary angiography (CTPA) remains a controversial criterion for ruling out acute pulmonary embolism (PE) in patients with a likely clinical probability. We set out to determine the risk of VTE and fatal PE after a normal CTPA in this patient category and compare these risk to those after a normal pulmonary angiogram of 1.7% (95%CI 1.0–2.7%) and 0.3% (95%CI 0.02–0.7%). A patient-level meta-analysis from 4 prospective diagnostic management studies that sequentially applied the Wells rule, D-dimer tests and CTPA to consecutive patients with clinically suspected acute PE. The primary outcome was the 3-month VTE incidence after a normal CTPA. A total of 6,148 patients were included with an overall PE prevalence of 24%. The 3-month VTE incidence in all 4,421 patients in whom PE was excluded at baseline was 1.2% (95%CI 0.48–2.6) and the risk of fatal PE was 0.11% (95%CI 0.02–0.70). In patients with a likely clinical probability the 3-month incidences of VTE and fatal PE were 2.0% (95%CI 1.0–4.1%) and 0.48% (95%CI 0.20–1.1%) after a normal CTPA. The 3-month incidence of VTE was 6.3% (95%CI 3.0–12) in patients with a Wells rule >6 points. In conclusion, this study suggests that a normal CTPA may be considered as a valid diagnostic criterion to rule out PE in the majority of patients with a likely clinical probability, although the risk of VTE is higher in subgroups such as patients with a Wells rule >6 points for which a closer follow-up should be considered.Supplementary Material to this article is available online at www.thrombosis-online.com.

Computerized Tomographic Pulmonary Angiography Compared with Ventilation-Perfusion Lung Scanning as Inital Diagnostic Modality for Patients with Suspected Pulmonary Embolism: A Randomized Controlled Trial.

Blood ◽  
2005 ◽  
Vol 106 (11) ◽  
pp. 1619-1619 ◽  
Author(s):  
David R. Anderson ◽  
Philip S. Wells ◽  
Susan Kahn ◽  
Marc Rodger ◽  
Michael J. Kovacs ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Randomized Controlled Trial ◽  
Controlled Trial ◽  
Pulmonary Angiography ◽  
Suspected Pulmonary Embolism ◽  
Cancer Management ◽  
Randomized Controlled ◽  
Lung Scanning ◽  
D Dimer

Abstract Ventilation-perfusion (VQ) lung scanning and computerized tomographic pulmonary angiography (CTPA) have been validated as imaging procedures for the evaluation of patients with suspected pulmonary embolism and are used widely. To compare the safety and utility of VQ scanning and CTPA we performed a multi-centre randomized controlled trial in patients presenting with clinically suspected acute pulmonary embolism. All patients were evaluated using an explicit clinical model to determine pretest probability (Wells score) and with D-dimer. Patients considered at low likelihood of pulmonary embolism (score < 4.5 and negative D-dimer) did not undergo further testing and were followed as a separate cohort. The remaining patients were randomized to undergo either VQ scanning or CTPA. Patients diagnosed with pulmonary embolism on the basis of a high probability VQ scan or a positive CTPA were treated. Other patients underwent bilateral venous ultrasound imaging of the proximal veins of lower extremities and those confirmed to have DVT were treated. Physicians were able to refer patients for traditional pulmonary angiography or serial ultrasonography after initial testing but switching of patients to have the alternative pulmonary imaging procedure was not permitted by the protocol. Patients in whom pulmonary embolism was considered excluded did not receive antithrombotic therapy and were followed for a three month period. The primary outcome was the development of symptomatic pulmonary embolism or proximal deep vein thrombosis in the follow-up period in patients in whom the diagnosis of pulmonary embolism had initially been excluded. 1577 patients were enrolled in the study of whom 172 entered the low risk cohort. 1405 patients were randomized, 694 to CTPA and 711 to VQ scanning. 19.2% (133) of patients in the CTPA versus 14.2% (101) were diagnosed with pulmonary embolism in the initial evaluation period (difference 5.0%, 95% CI 1.1% to 8.9%). Of those in whom pulmonary embolism was considered excluded 0.4% (2/561) patients undergoing CTPA versus 1.0% (6/610) patients undergoing VQ scanning developed venous thromboembolism in follow-up (difference −0.6%, 95% CI −1.6% to 0.3%) including one with fatal pulmonary embolism in the VQ group. All cause mortality was higher in the three month follow-up for patients undergoing VQ scanning (30/610, 4.9%) than for CTPA (17/694, 2.4%) in whom pulmonary embolism was considered excluded. Most of these deaths were from cancer. Management practices using bilateral ultrasonography with either VQ scanning or CTPA to exclude the diagnosis of pulmonary embolism resulted in low rates of venous thromboembolic complications. More patients were diagnosed intitally with pulmonary embolism using the CTPA approach and fewer patients died in this cohort in the three month follow-up period.

Age-Adjusted D-Dimer Cut-off Levels to Rule out Pulmonary Embolism: A Prospective Outcome Study

Blood ◽  
2013 ◽  
Vol 122 (21) ◽  
pp. LBA-4-LBA-4
Author(s):  
Marc Righini ◽  
Paul den Exter ◽  
Josien van ES ◽  
Franck Verschuren ◽  
Alexandre Ghuisen ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Clinical Practice ◽  
Emergency Room ◽  
Pulmonary Angiography ◽  
Outcome Study ◽  
Clinical Probability ◽  
Imaging Test ◽  
D Dimer ◽  
Rule Out

Abstract Introduction D-dimer testing allows to safely rule out pulmonary embolism (PE) without imaging test in approximately one third of outpatients. However, D-Dimer test is less useful as age increases because of a lower specificity. We recently derived an age-adjusted D-dimer cut-off value (age-adjusted cut-off = patient’s age x 10 in patients aged > 50 years, in μg/L), which allowed to significantly increase the proportion of patients in whom PE could be non-invasively excluded, without compromising safety. However, before being implemented in clinical practice, the safety of the age-adjusted cut-off should be verified in a management outcome study. Methods We designed a multicentre multinational prospective management outcome study. All consecutive outpatients seen in the emergency room of 22 centres in 4 countries with clinically suspected PE were assessed by a sequential diagnostic strategy based on the assessment of clinical probability, D-dimer measurement and computed tomography pulmonary angiography (CTPA). Patients with a D-dimer value between the usual threshold of 500 μg/L and their age-adjusted cut-off did not undergo CTPA and were left untreated and formally followed for a three-month period. Results Between January 1, 2010 and February 28, 2013, we included 3,377 patients. Mean age was 62 years, and 57% were females. Overall, the proportion of confirmed PE was 18%.  Among the 2,927 patients with a non-high clinical probability, 832 (28.4%) had a D-Dimer < 500 μg/L, and 345 additional patients (11.8%) had a D-Dimer comprised between 500 μg/L and their age-adjusted cut-off. During the 3-month follow-up period, out of the 345 patients with a D-Dimer between 500 μg/L and their age-adjusted cut-off, 18 patients received anticoagulation for another indication than PE. Of the remaining 327 patients, 7 died, and 7 underwent testing for suspected venous thromboembolism (VTE), of which one was confirmed. Therefore, the failure rate of the age-adjusted cut-off was 1/327: 0.3%, (95% CI 0.1 to 1.7%). Overall, 789 patients were aged 75 years or more, of them 697 had a non-high clinical probability. The proportion of patients with D-Dimer < 500 μg/L was 50/697 (7.2%). Another 161 patients had a D-Dimer above 500 μg/L and under their age-adjusted cut-off. Therefore, the proportion of patients > 75 with a negative D-Dimer using the age-adjusted cut-off was 211/697 (30.3%), of them none had a confirmed VTE during follow-up: 0.0%, (95%CI: 0.0 to 1.9%). Conclusions Our study demonstrates that the age-adjusted D-Dimer cut-off may now be used in clinical practice in emergency room patients with suspected PE. Combined with clinical probability, it increases the number of patients in whom PE can be excluded without imaging test, and this is particularly true among elderly patients, with a four-fold increased yield of D-dimer. A D-Dimer above 500 μg/L but under the age-adjusted cut-off safely excludes the diagnosis of PE, with a 3-month risk of VTE in line with that observed in patients with a D-Dimer under 500 μg/L or after a negative pulmonary angiography, the gold-standard test for PE. Disclosures: No relevant conflicts of interest to declare.

scholarly journals P039: Utilization of serum D-dimer assays and computed tomography pulmonary angiography (CTPA) scans in the diagnosis of pulmonary embolism among emergency department (ED) physicians

CJEM ◽  
2020 ◽  
Vol 22 (S1) ◽  
pp. S78-S78
Author(s):  
L. Salehi ◽  
P. Phalpher ◽  
H. Yu ◽  
M. Ossip ◽  
R. Valani ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Pulmonary Embolism ◽  
Decision Rules ◽  
Pulmonary Angiography ◽  
Low Risk ◽  
Urgent Care ◽  
Computed Tomography Pulmonary Angiography ◽  
Risk Patients ◽  
D Dimer ◽  
Rule Out

Introduction: As the availability of Computed Tomography Pulmonary Angiography (CTPA) to rule out pulmonary embolism (PE) increases, so too does its utilization, and consequent overutilization. A variety of evidence-based algorithms and decision rules using clinical criteria and D-Dimer testing have been proposed as instruments to allow physicians to safely rule out a PE in low-risk patients. However, studies have shown mixed results with respect to both physician uptake of these decision rules and their impact on improving ordering practices among physicians. The objective of this study is to describe the prevalence of D-Dimer utilization among ED physicians and its impact on positive yield rates of CTPAs in a community setting. Methods: Data was collected on all CTPA studies ordered by ED physicians at two very high-volume community hospitals and an affiliated urgent care centre during the 2-year period between January 1, 2016 and December 31, 2017. For each CTPA, we determined if 1) a D-Dimer had been ordered prior to CTPA, if 2) the D-Dimer was positive, and if 3) the CTPA was positive for a PE. Using a chi-square test, we compared the diagnostic yield for those patients who had a D-Dimer prior to their CTPA and those who did not. Results: A total of 2,811 CTPAs were included in the analysis. Of these, 964 CTPAs (34.3%) were ordered without a D-Dimer. Of those 1,847 patients who underwent D-Dimer testing prior to the CTPA, 343 (18.7%) underwent a CTPA despite a negative D-Dimer. When compared as a group, those CTPAs preceded by a D-Dimer showed no significant difference in positive yields when compared to those CTPAs ordered without a prior D-Dimer (9.9% versus 11.3%, p = 0.26). Conclusion: The findings of this study present a complicated picture of the impact of D-Dimer utilization on CTPA ordering patterns. There is evidence of suboptimal uptake of routine D-Dimer ordering, and adherence to guidelines in terms of forgoing CTPAs in low-risk patients with negative D-Dimers. While this study design leaves unanswered the question of how many CTPAs were avoided as a result of a negative D-Dimer, the finding of a similar positive yield among those patients who had a D-Dimer ordered versus those who did not is interesting, and illustrative of the issues arising from the high false-positive rates associated with D-Dimer screening.

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