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Electronic letters published:
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Appropriateness of excluding pulmonary embolism - In response :
Appropriatness of excluding pulmonary embolism
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Pierre-Marie Roy, MD, PhD University Hospital of Angers, France, Guy Meyer
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pmroy{at}chu-angers.fr Pierre-Marie Roy, et al.
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Dear sir, Doctor Hofstee’s remark is well-done. We indeed considered as appropriate the exclusion of pulmonary embolism on the basis of a negative ELISA D-dimer test even in patients with a high pretest probability because it was part of the recommendations of the European Society of Cardiology (1). We acknowledge that this criterion for excluding PE is debatable in 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 ELISA D-dimer test.(5) As a general rule, we considered as appropriate all diagnostic strategies that have been selected by international experts. The low rate of recurrent PE in the group of patients with an exclusion strategy based on these recommendations in our study reinforces this choice. Even with such a liberal definition only 57% of the patients underwent an appropriate diagnostic strategy and this was even lower when pulmonary embolism 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 pulmonary embolism in clinical practice is far from optimal. Pierre-Marie Roy and Guy Meyer Reference 1. Guidelines on diagnosis and management of acute pulmonary embolism. Task Force on Pulmonary Embolism, European Society of Cardiology. Eur Heart J. 2000;21(16):1301-36. 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(7511):259. 3. Perrier A, Desmarais S, Miron MJ, et al. Non-invasive diagnosis of venous thromboembolism in outpatients. Lancet. 1999;353(9148):190-5. 4. Perrier A, Roy PM, Aujesky D, 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(5):291-9. 5. Righini M, Aujesky D, Roy PM, 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(22):2483-7. Conflict of Interest:None declared |
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Herman MA Hofstee, MD Free University Academic Medical Center
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hma.hofstee{at}hi.nl Herman MA Hofstee
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Dear Sir, I read with great interest the study of Roy et al. However there is one thing that puzzled me. In figure 2 the authors state that pulmonary embolism (PE) had appropriately been ruled out when a spiral CT and ELISA D-dimer results were negative in the low clinical probability group and that only a negative D-dimer result is sufficient to rule out PE in the high probability group. From basic epidemiology and studies concerning the value of d-dimer in the diagnosis of pulmonary embolism we know that a negative d-dimer provides high certainty for excluding PE (low post-test probability of PE). On the other hand a negative D-dimer in a group with a high a-priori chance is insufficient to rule out PE (higher post-test probability of PE)(1). Could a print error have been occured? 1) Stein PD, Hull RD, Patel KC, Olson RE, Ghali WA, Brant R et al. D- dimer for the exclusion of acute venous thrombosis and pulmonary embolism: a systematic review. Ann Intern Med 2004; 140(8):589-602. Conflict of Interest:None declared |
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