Diagnosing pulmonary embolism: A question of too much choice?

Abstract

The diagnosis of pulmonary embolism (PE) is difficult with many patients treated without the disease or left untreated without an adequate diagnostic work up. Recent advances in PE diagnosis are reviewed. The use of risk stratification in PE diagnosis is strongly recommended and evidence on how it can best be performed summarized. The Ginsberg/Wells stratification rule is recommended currently as the best validated rule. Computed tomographic pulmonary angiography (CTPA) was found to have quite poor sensitivity and to be poorly validated. It is recommended as adequate as a positive test in moderate/high risk groups and an exclusionary test in low risk groups or where an adequate alternative diagnosis is found. For D‐Dimer tests the only test with adequate sensitivity and validation in management studies is the VIDAS© D‐Dimer. This is in low/intermediate risk groups in the ED population. The Simpli‐Red© test is also reviewed but is too insensitive for most populations. Echocardiography: this is good in compromised patients as it is a bedside test which when negative virtually excludes PE. If positive in the right setting it has a high positive predictive value. A negative echocardiogram predicts a benign clinical course for PE. The rest of the paper details the authors approach to integrating these new techniques with established algorithms and where progress is likely to occur in the next few years. These include improvements in CTPA (plus the addition of CT venography), new point of care D‐Dimer tests, better risk stratification rules and integration of new strategies with artificial neural networks or computerized guidelines.

Study of compliance with a clinical pathway for suspected pulmonary embolism

“…The usual incidence of PE found in ED cohorts in previously published studies tends to be 15-20%, but our sample had an incidence of only 8.4%. 2,7,16 The low incidence rate in our cohort was particularly difficult to explain as there was a corresponding low venous thromboembolism recurrence rate at 3 months follow up. This would indicate that failing to diagnose PE initially was unlikely.…”

Likelihood ratios increase diagnostic certainty in pulmonary embolism

“…Pulmonary embolism (PE) is one of the most difficult emergency diagnoses to confirm. The choice of diagnostic tests 1 is accompanied by a myriad of diagnostic algorithms 1–3 . However, it is essential to get as close as possible to certainty, particularly when excluding and, therefore, not treating a potentially fatal suspected diagnosis such as a PE.…”

Nonparametric Decision Support Systems in Medical Diagnosis

“…With ever skyrocketing medical costs (Benko, 2004), the use of information technology is seen as a much-needed means to help control and potentially to reduce medical direct costs (Intille, 2004). Deep vein thrombosis (DVT) and pulmo-nary embolism (PE) are medical conditions that are particularly difficult to diagnose in the acute setting (Mountain, 2003). Frequent usage of costly clinical laboratory tests to screen patients for further treatment is commonplace.…”

“…Frequent usage of costly clinical laboratory tests to screen patients for further treatment is commonplace. All too commonly, hospitals provide treatment to patients without PE as a preventative measure (Mountain, 2003). Furthermore, patient mortality, morbidity, and both direct and indirect costs for delayed diagnosis of these conditions also may be substantial.…”