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18 July 2006 | Volume 145 Issue 2 | Page 152
We indeed considered the exclusion of PE on the basis of a negative ELISA D-dimer result appropriate even in patients with a high pretest probability; doing so was part of the recommendations of the European Society of Cardiology (1). We acknowledge that this criterion for excluding PE is debatable from an evidence-based medicine point of view (2). It has been evaluated in large outcomes studies (3, 4), but only a few patients had the combination of a high pretest probability and a negative result on an ELISA D-dimer test (5). As a general rule, we considered as appropriate all diagnostic strategies endorsed by international experts. The low rate of recurrent PE in our study among patients excluded on the basis of these recommendations reinforces this choice. Even with such a liberal definition, only 57% of the patients underwent an appropriate diagnostic strategy; this rate was even lower when PE was excluded. Using more stringent criteria for appropriateness would have further reduced the rate of appropriate diagnostic strategies and would have reinforced our conclusion that the diagnosis of PE in clinical practice is far from optimal.
Potential Financial Conflicts of Interest: None disclosed. 1. Guidelines on diagnosis and management of acute pulmonary embolism. Task Force on Pulmonary Embolism, European Society of Cardiology. Eur Heart J. 2000;21:1301-36. [PMID: 10952823]. 2. Roy PM, Colombet I, Durieux P, Chatellier G, Sors H, Meyer G. Systematic review and meta-analysis of strategies for the diagnosis of suspected pulmonary embolism. BMJ. 2005;331:259 [PMID: 16052017]. 3. Perrier A, Desmarais S, Miron MJ, de Moerloose P, Lepage R, Slosman D, et al. Non-invasive diagnosis of venous thromboembolism in outpatients. Lancet. 1999;353:190-5. [PMID: 9923874].[Medline] 4. Perrier A, Roy PM, Aujesky D, Chagnon I, Howarth N, Gourdier AL, et al. Diagnosing pulmonary embolism in outpatients with clinical assessment, D-dimer measurement, venous ultrasound, and helical computed tomography: a multicenter management study. Am J Med. 2004;116:291-9. [PMID: 14984813].[Medline] 5. Righini M, Aujesky D, Roy PM, Cornuz J, de Moerloose P, Bounameaux H, et al. Clinical usefulness of D-dimer depending on clinical probability and cutoff value in outpatients with suspected pulmonary embolism. Arch Intern Med. 2004;164:2483-7. [PMID: 15596640].
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From University Hospital of Angers, 49033 Angers Cedex 01, France.
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