Article    Table of Contents                    Full Text of this article    PDF of this article (PDFs free after 6 months)    Summary for Patients    Summary for Patients (PDF)    Figures/Tables List    Related articles in Annals  Services    Send comment/rapid response letter    Notify a friend about this article    Alert me when this article is cited    Add to Personal Archive    Download to Citation Manager    ACP Search                            Get Permissions  Google Scholar    Search for Related Content  PubMed Articles in PubMed by Author:    Kruip, M. J.H.A.    Büller, H. R.    Related Articles in PubMed    PubMed Citation    PubMed

ARTICLE

Diagnostic Strategies for Excluding Pulmonary Embolism in Clinical Outcome Studies

A Systematic Review

Marieke J.H.A. Kruip, MD; Monique G.L. Leclercq, MD; Cees van der Heul, MD; Martin H. Prins, MD; and Harry R. Büller, MD

17 June 2003 | Volume 138 Issue 12 | Pages 941-951

Background: Pulmonary embolism is a common clinical disorder that is associated with high morbidity and mortality if untreated. It is important to confirm or rule out the diagnosis in patients with clinical suspicion of the disease.

Purpose: To evaluate various diagnostic strategies for excluding pulmonary embolism.

Data Sources: MEDLINE (1966 to February 2003), EMBASE, and DARE; study investigators; and reference lists.

Study Selection: Prospective clinical outcome studies.

Data Extraction: The researchers recorded the frequency of symptomatic venous thromboembolism over 3 months of follow-up in patients in whom pulmonary embolism had been excluded according to various strategies. Strategies were divided into three categories according to the number of rounds of diagnostic tests needed to exclude pulmonary embolism.

Data Synthesis: 25 studies involving more than 7000 patients were included. In all referred patients, two strategies—normal results on pulmonary angiography or lung scintigraphy and normal D-dimer levels combined with low clinical probability—safely excluded pulmonary embolism (failure rates 3%). In the second round of diagnostic tests, in patients who had had a nondiagnostic lung scan, both pulmonary angiography and serial leg testing for venous thrombosis were accurate and safe. When D-dimer testing combined with clinical probability was inconclusive, a normal perfusion lung scan safely excluded pulmonary embolism. Accumulating evidence shows that normal results on spiral computed tomography may also safely exclude the disease.

Conclusions: Many diagnostic strategies to exclude pulmonary embolism have been evaluated in consecutive patients. Interest is likely to increase in a simple, fast strategy, starting with a normal perfusion lung scan or a combination of normal D-dimer levels and low clinical probability. After the initial round of testing, a reliable diagnostic method, such as angiography or lung scintigraphy, is warranted.

Editors' Notes Context Several tests may help exclude pulmonary embolism. Which ones can safely guide treatment decisions? Contribution Twenty-five prospective studies in patients with suspected pulmonary embolism showed that several strategies are associated with a rate of thromboembolism of 3% or lower during 3 months without anticoagulant therapy. Successful strategies included normal results on pulmonary angiography or lung scintigraphy, low clinical probability and a normal D-dimer level, normal results on pulmonary angiography or serial leg testing after a nondiagnostic lung scan, and a normal lung scan with either moderate to high clinical probability or low clinical probability but an elevated D-dimer level. Implications Clinicians have many safe options with which to exclude pulmonary embolism. –The Editors

 

Author and Article Information

From St. Elisabeth Hospital, Tilburg; Medisch Spectrum Twente, Enschede; University of Maastricht, Maastricht; and Academic Medical Centre, Amsterdam, the Netherlands.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Marieke J.H.A. Kruip, MD, Department of Internal Medicine, St. Elisabeth Hospital, Postbus 90151, 5000 LC Tilburg, the Netherlands; e-mail, evert.janssen{at}zonnet.nl.

Current Author Addresses: Drs. Kruip and van der Heul: Department of Internal Medicine, St. Elisabeth Hospital, Postbus 90151, 5000 LC Tilburg, the Netherlands.

Dr. Leclercq: Department of Internal Medicine, Medisch Spectrum Twente, Postbus 50000, 7500 KA Enschede, the Netherlands.

Dr. Prins: Department of Clinical Epidemiology and Technology Assessment, University of Maastricht, Postbus 616, NL 6200 MD Maastricht, the Netherlands.

Dr. Büller: Department of Vascular Medicine, Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands.

Author Contributions: Conception and design: M.J.H.A. Kruip, M.G.L. Leclercq, M.H. Prins, H.R. Büller.

Analysis and interpretation of the data: M.J.H.A. Kruip, M.G.L. Leclercq, C. van der Heulm, M.H. Prins, H.R. Büller.

Drafting of the article: M.J.H.A. Kruip, C. van der Heul.

Critical revision of the article for important intellectual content: M.J.H.A. Kruip, M.G.L. Leclercq, C. van der Heul, M.H. Prins, H.R. Büller.

Final approval of the article: M.J.H.A. Kruip, M.H. Prins, H.R. Büller.

Provision of study materials or patients: M.J.H.A. Kruip.

Statistical expertise: M.H. Prins.

Collection and assembly of data: M.J.H.A. Kruip.

Related articles in Annals:

Summaries for Patients
Excluding Pulmonary Embolism Safely

Annals 2003 138: I-18. [Full Text]  

This article has been cited by other articles:

				S. Jouveshomme, I. Bohn, and A. Cazaban Diagnosis of pulmonary embolism in hospitalised patients: retrospective survey of an institutional standard Eur. Respir. J., December 1, 2007; 30(6): 1117 - 1123. [Abstract] [Full Text] [PDF]

				A. Scarsbrook, K. Bradley, F. Gleeson, A. M. Groves, S. J. Yates, T. Win, I. Kayani, J. Bomanji, and P. J. Ell Perfusion Scintigraphy Still has Important Role in Evaluation of Majority of Pregnant Patients with Suspicion of Pulmonary Embolism Radiology, August 1, 2007; 244(2): 623 - 625. [Full Text] [PDF]

				D. Luciani, S. Cavuto, L. Antiga, M. Miniati, S. Monti, M. Pistolesi, and G. Bertolini Bayes pulmonary embolism assisted diagnosis: a new expert system for clinical use Emerg. Med. J., March 1, 2007; 24(3): 157 - 164. [Abstract] [Full Text] [PDF]

				J. B. Segal, J. Eng, L. J. Tamariz, and E. B. Bass Review of the Evidence on Diagnosis of Deep Venous Thrombosis and Pulmonary Embolism Ann. Fam. Med, January 1, 2007; 5(1): 63 - 73. [Abstract] [Full Text] [PDF]

				U. R. O. Nyman, B. Jacobsson, M. D. Cham, D. F. Yankelevitz, and C. I. Henschke Routine CT Venography after CT for Pulmonary Embolism: Evidence-based Radiology or Hemorrhage from Anticoagulation of False-Positive Deep Venous Thrombosis? Radiology, December 1, 2006; 241(3): 945 - 947. [Full Text] [PDF]

				C. Kearon, J. S. Ginsberg, J. Douketis, A. G. Turpie, S. M. Bates, A. Y. Lee, M. A. Crowther, J. I. Weitz, P. Brill-Edwards, P. Wells, et al. An evaluation of D-dimer in the diagnosis of pulmonary embolism: a randomized trial. Ann Intern Med, June 6, 2006; 144(11): 812 - 821. [Abstract] [Full Text] [PDF]

				P.-M. Roy, G. Meyer, B. Vielle, C. Le Gall, F. Verschuren, F. Carpentier, P. Leveau, A. Furber, and for the EMDEPU Study Group* Appropriateness of Diagnostic Management and Outcomes of Suspected Pulmonary Embolism Ann Intern Med, February 7, 2006; 144(3): 157 - 164. [Abstract] [Full Text] [PDF]

				G. Le Gal, M. Righini, P.-M. Roy, O. Sanchez, D. Aujesky, H. Bounameaux, and A. Perrier Prediction of Pulmonary Embolism in the Emergency Department: The Revised Geneva Score Ann Intern Med, February 7, 2006; 144(3): 165 - 171. [Abstract] [Full Text] [PDF]

				H. C. Sox Better Care for Patients with Suspected Pulmonary Embolism Ann Intern Med, February 7, 2006; 144(3): 210 - 212. [Full Text] [PDF]

				G. Le Gal, M. Righini, P.-M. Roy, O. Sanchez, D. Aujesky, A. Perrier, and H. Bounameaux Value of D-Dimer Testing for the Exclusion of Pulmonary Embolism in Patients With Previous Venous Thromboembolism Arch Intern Med, January 23, 2006; 166(2): 176 - 180. [Abstract] [Full Text] [PDF]

				M. A. Rodger, C. N. Bredeson, G. Jones, P. Rasuli, F. Raymond, A. M. Clement, A. Karovitch, H. Brunette, D. Makropoulos, M. Reardon, et al. The Bedside Investigation of Pulmonary Embolism Diagnosis Study: A Double-blind Randomized Controlled Trial Comparing Combinations of 3 Bedside Tests vs Ventilation-Perfusion Scan for the Initial Investigation of Suspected Pulmonary Embolism Arch Intern Med, January 23, 2006; 166(2): 181 - 187. [Abstract] [Full Text] [PDF]

				Writing Group for the Christopher Study Investigat Effectiveness of Managing Suspected Pulmonary Embolism Using an Algorithm Combining Clinical Probability, D-Dimer Testing, and Computed Tomography JAMA, January 11, 2006; 295(2): 172 - 179. [Abstract] [Full Text] [PDF]

				P.-M. Roy, I. Colombet, P. Durieux, G. Chatellier, H. Sors, and G. Meyer Systematic review and meta-analysis of strategies for the diagnosis of suspected pulmonary embolism BMJ, July 30, 2005; 331(7511): 259. [Abstract] [Full Text] [PDF]

				A. Perrier, P.-M. Roy, O. Sanchez, G. Le Gal, G. Meyer, A.-L. Gourdier, A. Furber, M.-P. Revel, N. Howarth, A. Davido, et al. Multidetector-Row Computed Tomography in Suspected Pulmonary Embolism N. Engl. J. Med., April 28, 2005; 352(17): 1760 - 1768. [Abstract] [Full Text] [PDF]

				C. Kearon, J. S. Ginsberg, J. Douketis, M. A. Crowther, A. G. Turpie, S. M. Bates, A. Lee, P. Brill-Edwards, T. Finch, and M. Gent A Randomized Trial of Diagnostic Strategies after Normal Proximal Vein Ultrasonography for Suspected Deep Venous Thrombosis: D-Dimer Testing Compared with Repeated Ultrasonography Ann Intern Med, April 5, 2005; 142(7): 490 - 496. [Abstract] [Full Text] [PDF]

				S. W. Rathbun, T. L. Whitsett, and G. E. Raskob Negative D-dimer Result To Exclude Recurrent Deep Venous Thrombosis: A Management Trial Ann Intern Med, December 7, 2004; 141(11): 839 - 845. [Abstract] [Full Text] [PDF]

				L. K. Moores, W. L. Jackson Jr., A. F. Shorr, and J. L. Jackson Meta-Analysis: Outcomes in Patients with Suspected Pulmonary Embolism Managed with Computed Tomographic Pulmonary Angiography Ann Intern Med, December 7, 2004; 141(11): 866 - 874. [Abstract] [Full Text] [PDF]

				M. K Gould Review: negative ELISA results are best for excluding a diagnosis of deep venous thrombosis or pulmonary embolism Evid. Based Med., November 1, 2004; 9(6): 186 - 186. [Full Text] [PDF]

				T. L Fancher, R. H White, and R. L Kravitz Combined use of rapid D-dimer testing and estimation of clinical probability in the diagnosis of deep vein thrombosis: systematic review BMJ, October 9, 2004; 329(7470): 821. [Abstract] [Full Text] [PDF]

				K. Kroenke and L. Logio Update in General Internal Medicine Ann Intern Med, August 3, 2004; 141(3): 213 - 220. [Full Text] [PDF]

				M Riedel Diagnosing pulmonary embolism Postgrad. Med. J., June 1, 2004; 80(944): 309 - 319. [Abstract] [Full Text] [PDF]

				U. J. Schoepf, S. Z. Goldhaber, and P. Costello Spiral Computed Tomography for Acute Pulmonary Embolism Circulation, May 11, 2004; 109(18): 2160 - 2167. [Abstract] [Full Text] [PDF]

				A. Perrier D-dimer for Suspected Pulmonary Embolism: Whom Should We Test? Chest, March 1, 2004; 125(3): 807 - 809. [Full Text] [PDF]

				S. W. Rathbun, T. L. Whitsett, S. K. Vesely, and G. E. Raskob Clinical Utility of D-dimer in Patients With Suspected Pulmonary Embolism and Nondiagnostic Lung Scans or Negative CT Findings Chest, March 1, 2004; 125(3): 851 - 855. [Abstract] [Full Text] [PDF]