Use of CT Angiography in a Country with Low Pulmonary Embolism Prevalence: Correlation with Clinical Pretest Probability and D-dimer Values

Abstract Current diagnostic workup of patients with suspected acute pulmonary embolism (PE) usually starts with the assessment of clinical pretest probability, using clinical prediction rules and plasma D-dimer measurement. Although an accurate diagnosis of acute pulmonary embolism (PE) in patients is thus of crucial importance, the diagnostic management of suspected PE is still challenging. A 60-year-old man with chest pain and expectoration of blood was admitted to the Department of Cardiology, General Hospital in Cuprija, Serbia. After physical examination and laboratory analyses, the diagnosis of Right side pleuropne monia and acute pulmonary embolism was established. Clinically, patient was hemodynamically stable, auscultative slightly weaker respiratory sound right basal, without pretibial edema. Laboratory: C-reactive protein (CRP) 132.9 mg/L, Leukocytes (Le) 18.9x109/L, Erythrocytes (Er) 3.23x1012/L, Haemoglobin (Hgb) 113 g/L, Platelets (Plt) 79x109/L, D-dimer 35.2. On the third day after admission, D-dimer was increased and platelet count was decreased (Plt up to 62x109/L). According to Wells’ rules, score was 2.5 (without symptoms on admission), a normal clinical finding with clinical manifestation of hemoptysis and chest pain, which represents the intermediate level of clinical probability of PE. After the recidive of PE, Wells’ score was 6.5. In summary, this study suggests that Wells’ score, based on a patient’s risk for pulmonary embolism, is a valuable guidance for decision-making in combination with knowledge and experience of clinicians. Clinicians should use validated clinical prediction rules to estimate pretest probability in patients in whom acute PE is being consiered.

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D-dimer threshold increase with pretest probability unlikely for pulmonary embolism to decrease unnecessary computerized tomographic pulmonary angiography

Journal of Thrombosis and Haemostasis ◽

10.1111/j.1538-7836.2012.04647.x ◽

2012 ◽

Vol 10 (4) ◽

pp. 572-581 ◽

Cited By ~ 49

Author(s):

J. A. KLINE ◽

M. M. HOGG ◽

D. M. COURTNEY ◽

C. D. MILLER ◽

A. E. JONES ◽

...

Keyword(s):

Pulmonary Embolism ◽

Pulmonary Angiography ◽

Pretest Probability ◽

D Dimer ◽

Threshold Increase

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Performance of the Quantitative Latex Immunoturbidimetric D-dimer Assay for the Diagnosis of Acute Pulmonary Embolism at Rafik Hariri University Hospital

International journal of epidemiologic research ◽

10.34172/ijer.2020.22 ◽

2020 ◽

Vol 7 (3) ◽

pp. 125-128

Author(s):

Rida Salman ◽

Mira Alsheikh ◽

Rim Ismail

Keyword(s):

Pulmonary Embolism ◽

Negative Predictive Value ◽

Ct Angiography ◽

Sensitivity And Specificity ◽

Predictive Value ◽

Retrospective Chart Review ◽

Latex Agglutination ◽

University Hospital ◽

Acute Pe ◽

D Dimer

Background and aims: The diagnostic workup for pulmonary embolism (PE) includes D-dimer assay and computed tomographic angiography. Several D-dimer assays have been approved for PE diagnosis with different sensitivity and specificity. We aimed to study the sensitivity and specificity of the quantitative latex agglutination D-dimer assay used in a referral teaching hospital in Lebanon for the diagnosis of acute PE. Methods: Using a retrospective chart review, we studied 300 patients who had D-dimer test at Rafik Hariri University Hospital in the period between January 1, 2012 and December 31, 2013. Accordingly, 93 patients had a CT angiography after being suspected to have acute PE. A statistical table 2*2 was used to compare the results of CT angiography and D-dimer test. Results: Thirteen patients (13.97%) had PE and 60 patients (64.51%) had positive D-dimer test. Quantitative latex agglutination D-dimer assay had a sensitivity of 69%, specificity of 36%, and negative predictive value of 88%. False positive ratio was also 64%. Moreover, the receiver operating characteristic (ROC) curve was obtained with an area under the curve measuring 0.527. Conclusion: Quantitative latex agglutination D-dimer assay has a high negative predictive value; thus, it can exclude a PE diagnosis if it is associated with low clinical pretest probability.

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Investigation of Suspected Pulmonary Embolism at Hutt Valley Hospital with CT Pulmonary Angiography: Current Practice and Opportunities for Improvement

Advances in Medicine ◽

10.1155/2015/357576 ◽

2015 ◽

Vol 2015 ◽

pp. 1-5 ◽

Cited By ~ 2

Author(s):

Nick Kennedy ◽

Sisira Jayathissa ◽

Paul Healy

Keyword(s):

Pulmonary Embolism ◽

Current Practice ◽

Pulmonary Angiography ◽

Pretest Probability ◽

British Thoracic Society ◽

Suspected Pulmonary Embolism ◽

Ct Pulmonary Angiography ◽

Wells Score ◽

Positive Rate ◽

D Dimer

Aims. To study the use of CT pulmonary angiography (CTPA) at Hutt Hospital and investigate the use of pretest probability scoring in the assessment of patients with suspected pulmonary embolism (PE).Methods. We studied patients with suspected PE that underwent CTPA between January and May 2012 and collected data on demographics, use of pretest probability scoring, and use of D Dimer and compared our practice with the British Thoracic Society (BTS) guideline.Results. 105 patients underwent CTPA and 15% of patients had PE. 13% of patients had a Wells score prior to their scan. Wells score calculated by researchers revealed 54%, 36%, and 8% patients had low, medium, and high risk pretest probabilities and 8%, 20%, and 50% of these patients had positive scans. D Dimer was performed in 58% of patients and no patients with a negative D Dimer had a PE.Conclusion. The CTPA positive rate was similar to other contemporary studies but lower than previous New Zealand studies and some international guidelines. Risk stratification of suspected PE using Wells score and D Dimer was underutilised. A number of scans could have been safely avoided by using accepted guidelines reducing resources use and improving patient safety.

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Pulmonary Embolism

10.2310/em.4753 ◽

2019 ◽

Author(s):

Nadav Granat ◽

Evan Avraham Alpert

Keyword(s):

Computed Tomography ◽

Pulmonary Embolism ◽

Blood Clot ◽

Pretest Probability ◽

Treatment Modalities ◽

Pulmonary Vasculature ◽

Pulmonary Angiogram ◽

Catheter Directed Thrombolysis ◽

D Dimer ◽

Rule Out

Pulmonary embolism is caused by a blood clot that travels from the deep veins through the heart and then lodges in the pulmonary vasculature. Common symptoms include pleuritic chest pain, dyspnea, or palpitations. Clinical scores such as the Wells score and Revised Geneva score can be used to assess the pretest probability of pulmonary embolism (PE) and guide work-up such as deciding to order D-dimer testing or imaging. However, clinical gestalt can also accurately assess the pretest probability of PE. The Pulmonary Embolism Rule-out Criteria is a decision rule that can be used to rule out PE without further testing. Imaging modalities include computed tomography pulmonary angiogram or ventilation/perfusion scanning. Novel or new oral anticoagulants are becoming the mainstay of treatment for the hemodynamically stable patient with pulmonary embolism. For the patient who is hemodynamically unstable, treatment modalities include intravenous alteplase, catheter-directed thrombolysis, surgical embolectomy, and catheter-directed embolectomy. A subset of patients with PE can be treated as outpatients. This review contains 1 figure, 4 tables, and 55 references. Key Words: anticoagulants, antithrombins, D-dimer, low-molecular-weight heparin, mechanical thrombolysis, multidetector computed tomography, radionuclide imaging, unfractionated heparin, pulmonary embolism, tissue plasminogen activator, warfarin

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Role of CT angiography in detecting acute pulmonary embolism associated with COVID-19 pneumonia

La radiologia medica ◽

10.1007/s11547-021-01415-y ◽

2021 ◽

Author(s):

Gabriele Masselli ◽

Maria Almberger ◽

Alessandra Tortora ◽

Lucia Capoccia ◽

Miriam Dolciami ◽

...

Keyword(s):

Pulmonary Embolism ◽

Ct Angiography ◽

Arterial Oxygen Saturation ◽

Severe Form ◽

Arterial Oxygen ◽

Nasopharyngeal Swab ◽

Inclusion Criteria ◽

Illness Onset ◽

Iodinated Contrast ◽

D Dimer

Abstract Purpose Recently coronavirus disease (COVID-19) caused a global pandemic, characterized by acute respiratory distress syndrome (ARDS). The aim of our study was to detect pulmonary embolism (PE) in patients with severe form of COVID-19 infection using pulmonary CT angiography, and its associations with clinical and laboratory parameters. Methods From March to December 2020, we performed a prospective monocentric study collecting data from 374 consecutive patients with confirmed SARS-CoV-2 infection, using real-time reverse-transcriptase polymerase-chain-reaction (rRT-PCR) assay of nasopharyngeal swab specimens. We subsequently selected patients with at least two of the following inclusion criteria: (1) severe acute respiratory symptoms (such as dyspnea, persistent cough, fever > 37.5 °C, fatigue, etc.); (2) arterial oxygen saturation ≤ 93% at rest; (3) elevated D-dimer (≥ 500 ng/mL) and C-reactive protein levels (≥ 0.50 mg/dL); and (4) presence of comorbidities. A total of 63/374 (17%) patients met the inclusion criteria and underwent CT angiography during intravenous injection of iodinated contrast agent (Iomeprol 400 mgI/mL). Statistical analysis was performed using Wilcoxon rank-sum and Chi-square tests. Results About, 26/60 patients (40%) were found positive for PE at chest CT angiography. In these patients, D-dimer and CRP values were significantly higher, while a reduction in SaO2 < 93% was more common than in patients without PE (P < 0.001). Median time between illness onset and CT scan was significantly longer (15 days; P < 0.001) in patients with PE. These were more likely to be admitted to the Intensive Care Unit (19/26 vs. 11/34 patients; P < 0.001) and required mechanical ventilation more frequently than those without PE (15/26 patients vs. 9/34 patients; P < 0.001). Vascular enlargement was significantly more frequent in patients with PE than in those without (P = 0.041). Conclusions Our results pointed out that patients affected by severe clinical features of COVID-19 associated with comorbidities and significant increase of D-dimer levels developed acute mono- or bi-lateral pulmonary embolism in 40% of cases. Therefore, the use of CT angiography rather than non-contrast CT should be considered in these patients, allowing a better evaluation, that can help the management and improve the outcomes.

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