The Role of a Decision Rule in Symptomatic Pulmonary Embolism Patients with a Non-high Probability Ventilation-perfusion Scan

1997 ◽  
Vol 78 (02) ◽  
pp. 794-798 ◽  
Author(s):  
Bowine C Michel ◽  
Philomeen M M Kuijer ◽  
Joseph McDonnell ◽  
Edwin J R van Beek ◽  
Frans F H Rutten ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Decision Rule ◽  
Predictive Value ◽  
Patient Population ◽  
High Probability ◽  
Characteristic Curve ◽  
Stepwise Logistic Regression ◽  
Pulmonary Angiogram ◽  
Symptomatic Pulmonary Embolism ◽  
Perfusion Scan

Summary Background: In order to improve the use of information contained in the medical history and physical examination in patients with suspected pulmonary embolism and a non-high probability ventilation-perfusion scan, we assessed whether a simple, quantitative decision rule could be derived for the diagnosis or exclusion of pulmonary embolism. Methods: In 140 consecutive symptomatic patients with a non- high probability ventilation-perfusion scan and an interpretable pulmonary angiogram, various clinical and lung scan items were collected prospectively and analyzed by multivariate stepwise logistic regression analysis to identify the most informative combination of items. Results: The prevalence of proven pulmonary embolism in the patient population was 27.1%. A decision rule containing the presence of wheezing, previous deep venous thrombosis, recently developed or worsened cough, body temperature above 37° C and multiple defects on the perfusion scan was constructed. For the rule the area under the Receiver Operating Characteristic curve was larger than that of the prior probability of pulmonary embolism as assessed by the physician at presentation (0.76 versus 0.59; p = 0.0097). At the cut-off point with the maximal positive predictive value 2% of the patients scored positive, at the cut-off point with the maximal negative predictive value pulmonary embolism could be excluded in 16% of the patients. Conclusions: We derived a simple decision rule containing 5 easily interpretable variables for the patient population specified. The optimal use of the rule appears to be in the exclusion of pulmonary embolism. Prospective validation of this rule is indicated to confirm its clinical utility.

scholarly journals Pulmonary embolism in patients with chronic hypoxemia

2010 ◽  
Vol 63 (7-8) ◽  
pp. 492-496 ◽  
Author(s):  
Lidija Ristic ◽  
Milan Rancic ◽  
Tatjana Pejcic
Keyword(s):  
Pulmonary Embolism ◽  
Pulmonary Artery ◽  
Predictive Value ◽  
Diagnostic Study ◽  
Diagnostic Strategy ◽  
Radiological Findings ◽  
Group I ◽  
Perfusion Scan ◽  
Group Ii ◽  
Chronic Hypoxemia

Introduction. The aim of this prospective, originally designed, clinical - diagnostic study including 200 chronic hypoxemic patients was to assess the possibility of implementation of noninvasive diagnostic strategy and to investigate the incidence of pulmonary embolism and parameters of diagnostic accuracy of radiological findings according to Shintz criteria, echocardiography, lung perfusion scanning according to PIOPED criteria. Material and methods. The study included 200 chronic hypoxemic patients divided into 2 groups, the group I consisting of 42 women and 58 men and the group II consisting of 48 women and 52 men. Results and conclusion. Out of 200 hypoxemic patients, 49 patients (24.5%) were found to have pulmonary embolism. In the group I of 100 patients (42 women and 58 men) with chronic hypoxemia and secondary erythrocytosis the diagnosis of pulmonary embolism was confirmed in 39%, that being statistically significantly different (p<0.001) from 100 patients (48 women and 52 men) in the group II with chronic hypoxemia without secondary erythrocytosis, where pulmonary embolism was found in 10% of the patients. The predictive value was positive for direct radiological signs in 92.3% of patients in the group I for PTE, for indirect ones in 74.35%, and in the group II it was positive for direct radiological signs in 60% and for indirect ones in 90%. The predictive value of perfusion scan was positive in 59% of the group I and in only 22% of the group II. The predictive value for high pressure in the pulmonary artery was positive in 93.7% of the group I and in 66.6% of the group II. The following were found to be a variable predictor: hypoxemia, enlargement of the pulmonary artery, peripheral oligemia and elevation of diaphragm. Logistic regression according to backward - conditional method showed that the chronic hypoxemic patients with secondary erythrocytosis, who had radiological sign of peripheral oligemia - Westermark sign, had 2.286 times higher probability of having pulmonary embolism than similar patients without this sign.

scholarly journals Efficacy of Ventilation Perfusion Lung Scanning and Computed Tomography Pulmonary Angiography for Chronic Thrombo-Embolic Pulmonary Hypertension

2020 ◽  
pp. 1-6
Author(s):  
Geoff Currie ◽  
Geoff Currie ◽  
Janelle Wheat ◽  
Michael Tong
Keyword(s):  
Computed Tomography ◽  
Pulmonary Hypertension ◽  
Diagnostic Imaging ◽  
Sensitivity And Specificity ◽  
Predictive Value ◽  
High Probability ◽  
Lung Ventilation ◽  
Final Diagnosis ◽  
Pulmonary Angiography ◽  
Pulmonary Angiogram

Introduction: The diagnostic approach for patients with suspected Chronic Thrombo-Embolic Pulmonary Hypertension (CTEPH) is a combination of clinical and pre-test probability assessment, and diagnostic imaging of computed tomography pulmonary angiogram (CTPA) or lung ventilation and perfusion scintigraphy (V/Q). There is a paucity of literature, particularly for Southeast Asia (SEA) populations, regarding the efficacy of these imaging approaches. This study investigated the sensitivity and specificity of V/Q and CTPA in the diagnosis of CTEPH. Methods: A retrospective analysis was undertaken on 133 consecutive patients presenting for pulmonary hypertension (PH). The population included 42 males, 91 females, 683 V/Q images and 6288 CTPA images for patients in the age range 18 to 93 years (mean 66). All data was retrospectively analysed by two nuclear medicine physicians and classified as findings consistent with CTEPH or inconsistent with CTEPH. These classifications were independently and collectively correlated with a final diagnosis of CTEPH or no CTEPH. Results: The accuracy, sensitivity, and specificity of V/Q for detection of CTEPH was 83.5%, 57.5% and 97.7% respectively, with a positive predictive value (PPV) of 93.1% and a negative predictive value (NPV) of 80.8% when only high probability reports were considered CTEPH positive. The accuracy, sensitivity, and specificity of V/Q for detection of CTEPH was 96.2%, 97.9% and 95.4% respectively, with a PPV of 92.0% and a NPV of 98.8% when both high probability and intermediate probability reports were considered CTEPH positive. The accuracy, sensitivity and specificity of CTPA for detection of CTEPH were 70.7%, 19.2% and 98.8% respectively, with 90% PPV and 69.1% NPV. All 47 CTEPH studies were reported as having abnormal lung perfusion. Conclusion: This investigation has shown that V/Q is a more valuable diagnostic imaging tool in detecting CTEPH than CTPA. In suspected CTEPH, a high/intermediate V/Q report is consistent with a positive diagnosis. This is an important finding as CTEPH is a potentially treatable condition.

Clinical Evaluation of a Monoclonal Antibody-based Enzyme Immunoassay for Fibrin Degradation Products in Patients with Clinically Suspected Pulmonary Embolism

2000 ◽  
Vol 83 (06) ◽  
pp. 892-895 ◽  
Author(s):  
Wouter de Monyé ◽  
Jeroen Lijmer ◽  
Willem Nieuwenhuizen ◽  
Harry Büller ◽  
Menno Huisman ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Negative Predictive Value ◽  
Predictive Value ◽  
Operating Characteristic ◽  
Degradation Products ◽  
Characteristic Curve ◽  
Suspected Pulmonary Embolism ◽  
Fibrin Degradation Products ◽  
Potential Clinical Utility ◽  
Sensitivity Specificity

SummaryWe prospectively evaluated the diagnostic accuracy of the Fibrinostika® FbDP assay in 304 consecutive patients with suspected pulmonary embolism and examined potentially useful cut-off points at which the disease can be excluded. The prevalence of pulmonary embolism was 31%. The assay generated an area under the Receiver Operating Characteristic curve of 0.79 (95% CI 0.73–0.84). A cut-off point of 0.05 µ,g/ml yielded a sensitivity, specificity, negative predictive value and an exclusion efficiency of 100% (95% CI 96–100), 5% (95% CI 2–9), 100% (95% CI 69–100) and 3% (95% CI 2–6), respectively. A clinically useful cut-off point seems to be 0.11 µ,g/ml which corresponded with a sensitivity, specificity, negative predictive value and an exclusion efficiency of 96% (95% CI 90–99), 27% (95% CI 24–28), 93% (95% CI 84–98) and 20% (95% CI 16–25), respectively. We conclude that the assay has potential clinical utility for the exclusion of pulmonary embolism, but it cannot be used as a sole test.

scholarly journals Diagnostic performance of D-dimer in predicting pulmonary embolism in tuberculous pleural effusion patients

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Xiaoming Li ◽  
Yajing Qin ◽  
Wenjing Ye ◽  
Xi Chen ◽  
Dezhi Sun ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Pleural Effusion ◽  
Predictive Value ◽  
Diagnostic Performance ◽  
Characteristic Curve ◽  
Pulmonary Angiography ◽  
Potential Mechanism ◽  
Tuberculous Pleural Effusion ◽  
Sensitivity Specificity ◽  
D Dimer

Abstract Background Tuberculous pleural effusion (TPE) patients usually have elevated D-dimer levels. The diagnostic performance of D-dimer in predicting pulmonary embolism (PE) in the TPE population is unclear. This study aimed to assess the diagnostic performance of D-dimer for PE in the TPE population and explore its potential mechanism. Methods We retrospectively analysed patients who were admitted to Xinhua Hospital and Weifang Respiratory Disease Hospital with confirmed TPE between March 2014 and January 2020. D-dimer levels were compared between patients with and without PE. To test the diagnostic performance of D-dimer in predicting PE, receiver operating characteristic curve analysis was performed. Positive predictive value (PPV) and negative predictive value (NPV) were also reported. To explore the potential mechanism of PE in TPE, inflammatory biomarkers were compared between PE and non-PE patients. Results This study included 248 patients (170 males and 78 females) aged 43 ± 20.6 years. Elevated D-dimer levels (≥ 0.5 mg/L) were detected in 186/248 (75%) patients. Of the 150 patients who underwent computed tomography pulmonary angiography, 29 were diagnosed with PE. Among the TPE population, the PE patients had significantly higher D-dimer levels than the non-PE patients (median, 1.06 mg/L vs. 0.84 mg/L, P < 0.05). The optimal cut-off value for D-dimer in predicting PE in TPE was 1.18 mg/L, with a sensitivity of 89.7% and a specificity of 77.8% (area under curve, 0.893; 95% confidence interval 0.839–0.947; P < 0.01). The PPV was 49.1%, while the NPV was 96.9% at a D-dimer cut-off of 1.18 mg/L for PE. PE patients had lower median WBC and interleukin (IL)-8 values (5.14 × 109/L vs. 6.1 × 109/L, P < 0.05; 30.2 pg/ml vs. 89.7 pg/ml, P < 0.05) but a higher median IL-2 receptor value (1964.8 pg/ml vs. 961.2 pg/ml, P < 0.01) than those in the non-PE patients. Conclusions D-dimer is an objective biomarker for predicting PE in patients with TPE. A D-dimer cut-off of 1.18 mg/L in the TPE population may reduce unnecessary radiological tests due to its excellent sensitivity, specificity, and NPV for PE. The imbalance of prothrombotic and antithrombotic cytokines may partly be attributed to the formation of pulmonary emboli in patients with TPE.

SILENT PULMONARY EMBOLISM IN PATIENTS WITH DEEP VEIN THROMBOSIS

1987 ◽  
Author(s):  
M V Huisman ◽  
H R Buller ◽  
J W ten Cate ◽  
E A van Royen ◽  
J Vreeken
Keyword(s):  
Pulmonary Embolism ◽  
Deep Vein Thrombosis ◽  
Venous Thrombosis ◽  
Deep Venous Thrombosis ◽  
High Probability ◽  
Anticoagulant Treatment ◽  
Vein Thrombosis ◽  
Symptomatic Pulmonary Embolism ◽  
Lung Scan ◽  
Deep Vein

In patients presenting with clinically suspected deep vein thrombosis symptomatic pulmonary embolism is rarely apparent. To assess the prevalence of asymptomatic pulmonary embolism in outpatients with proven deep vein thrombosis, perfusion ventilation lungscans were performed in 101 consecutive patients at the first day of treatment and after one week of therapy. Fifty-one percent of these patients had a high probability lung-scan at the start of treatment. In control patients (n=44) without deep venous thrombosis but referred through the same filter, the prevalence of high-proba-bility scans was only 5%. After one week of anticoagulant treatment complete to partial improvement was observed in 55% of the patients while in another 24% of the patients the scan remained normal.It is concluded that lungscan detected asymptomatic pulmonary embolism occurs frequently in patients presenting with symptomatic deep venous thrombosis and that the majority of these emboli resolve within one week of anticoagulant treatment.

Tissue plasminogen activator as a novel diagnostic aid in acute pulmonary embolism

VASA ◽  
2014 ◽  
Vol 43 (6) ◽  
pp. 450-458 ◽  
Author(s):  
Julio Flores ◽  
Ángel García-Avello ◽  
Esther Alonso ◽  
Antonio Ruíz ◽  
Olga Navarrete ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Negative Predictive Value ◽  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Predictive Value ◽  
Acute Pulmonary Embolism ◽  
Enzyme Linked Immunosorbent Assay ◽  
Diagnostic Utility ◽  
Tissue Plasminogen ◽  
D Dimer

Background: We evaluated the diagnostic efficacy of tissue plasminogen activator (tPA), using an enzyme-linked immunosorbent assay (ELISA) and compared it with an ELISA D-dimer (VIDAS D-dimer) in acute pulmonary embolism (PE). Patients and methods: We studied 127 consecutive outpatients with clinically suspected PE. The diagnosis of PE was based on a clinical probability pretest for PE and a strict protocol of imaging studies. A plasma sample to measure the levels of tPA and D-dimer was obtained at enrollment. Diagnostic accuracy for tPA and D-dimer was determined by the area under the receiver operating characteristic (ROC) curve. Sensitivity, specificity, predictive values, and the diagnostic utility of tPA with a cutoff of 8.5 ng/mL and D-dimer with a cutoff of 500 ng/mL, were calculated for PE diagnosis. Results: PE was confirmed in 41 patients (32 %). Areas under ROC curves were 0.86 for D-dimer and 0.71 for tPA. The sensitivity/negative predictive value for D-dimer using a cutoff of 500 ng/mL, and tPA using a cutoff of 8.5 ng/mL, were 95 % (95 % CI, 88–100 %)/95 % (95 % CI, 88–100 %) and 95 % (95 % CI, 88–100 %)/94 %), respectively. The diagnostic utility to exclude PE was 28.3 % (95 % CI, 21–37 %) for D-dimer and 24.4 % (95 % CI, 17–33 %) for tPA. Conclusions: The tPA with a cutoff of 8.5 ng/mL has a high sensitivity and negative predictive value for exclusion of PE, similar to those observed for the VIDAS D-dimer with a cutoff of 500 ng/mL, although the diagnostic utility was slightly higher for the D-dimer.

A Comparative Analysis of D-Dimer Assays in Patients with Clinically Suspected Pulmonary Embolism

1993 ◽  
Vol 70 (03) ◽  
pp. 408-413 ◽  
Author(s):  
Edwin J R van Beek ◽  
Bram van den Ende ◽  
René J Berckmans ◽  
Yvonne T van der Heide ◽  
Dees P M Brandjes ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Comparative Analysis ◽  
High Probability ◽  
Pulmonary Emboli ◽  
Plasma Samples ◽  
Suspected Pulmonary Embolism ◽  
Lung Scan ◽  
D Dimer

SummaryTo avoid angiography in patients with clinically suspected pulmonary embolism and non-diagnostic lung scan results, the use of D-dimer has been advocated. We assessed plasma samples of 151 consecutive patients with clinically suspected pulmonary embolism. Lung scan results were: normal (43), high probability (48) and non-diagnostic (60; angiography performed in 43; 12 pulmonary emboli). Reproducibility, cut-off values, specificity, and percentage of patients in whom angiography could be avoided (with sensitivity 100%) were determined for two latex and four ELISA assays.The latex methods (cut-off 500 μg/1) agreed with corresponding ELISA tests in 83% (15% normal latex, abnormal ELISA) and 81% (7% normal latex, abnormal ELISA). ELISA methods showed considerable within- (2–17%) and between-assay Variation (12–26%). Cut-off values were 25 μg/l (Behring), 50 μg/l (Agen), 300 μg/l (Stago) and 550 μg/l (Organon). Specificity was 14–38%; in 4–15% of patients angiography could be avoided.We conclude that latex D-dimer assays appear not useful, whereas ELISA methods may be of limited value in the exclusion of pulmonary embolism.

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