Diagnostic approach to patients with suspected pulmonary embolism: a report from the real world

Abstract

SummaryThis study was carried out to examine the diagnostic approach to patients with suspected pulmonary embolism (PE) in a university hospital. A retrospective case record review of 251 patients with suspected pulmonary embolism was carried out according to a standard protocol, which looked at the utilisation of imaging techniques and compared clinical diagnoses with a standardised diagnosis established according to current recommendations. Isotopic lung scan was the most commonly used technique (73%), followed by leg vein sonography (36%) and contrast venography (31%). Lung arteriography was done in only 7% of patients. Among the 205 patients with a clinical diagnosis of PE, 115 (56%) would be diagnosed as having PE according to the standard criteria, 84 (41%) would be unclassified, and six (3%) would not be regarded as having PE. Among patients who were diagnosed as having PE and received anticoagulant therapy, 32% did not have the diagnosis confirmed by an imaging technique. Most of these had a non-diagnostic lung scan which, despite evidence to the contrary, seemed to be interpreted as confirmation of PE. We conclude that clinicians do not seem to follow current recommendations when approaching patients with suspected PE. In particular, there is an over-reliance on lung scans, and the significance of non-diagnostic scans was often misinterpreted. Arteriography was underused. These results emphasise the need to take measures to implement practice guidelines and to explore the usefulness of newer non-invasive techniques.

Diagnosing pulmonary embolism: A question of too much choice?

“…Its protean presentations coupled with complex diagnostic pathways contribute to this feeling. Recent studies suggest that complete investigations to confirm or exclude the diagnosis often don’t occur 1–6 . In my own institution a recent review of 400 cases revealed that fewer than 50% of cases had a definitive diagnosis made after an initial test for PE.…”

Pulmonary embolism: an unsuspected killer

“…The rate of pulmonary angiography performed in these patients is typically less than 12%, however, with most physicians unwilling or unable to obtain angiography routinely in the workup of PE [24,78,79,86,87]. Some authors believe that failure to obtain angiography in all cases that have nondiagnostic studies is unacceptable due to the likelihood of missed pulmonary emboli.…”

Diagnostic approach to patients with suspected pulmonary embolism

“…Sir, The observation that patients with indeterminate isotope lung scans received anticoagulant therapy without the benefit of validation or refutation of pulmonary thrombo-embolic disease through the use of investigative modalities for lower limb deep vein thrombosis,1 resonates with my own observation that there is widespread underutilisation of the principle of a ‘one stop’ facility for streamlining investigation and treatment of common disorders. A ‘one stop’ facility for investigation of pulmonary thrombo-embolic disease would have ensured that patients with indeterminate isotope lung scans could proceed to an investigative evaluation of the lower limbs for deep vein thrombosis at the same sitting.…”

“…The generalisability of this principle is exemplified by the investigation of the underlying cause of iron deficiency anaemia in a ‘one stop’ facility utilising upper gastrointestinal endoscopy and colonoscopy at the same sitting, resulting in one of the highest yields for identification of multiple pathology as the aetiopathogenetic basis of this disorder,2 and also reducing the likelihood of delayed recognition of ‘clinically silent’ underlying causes such as left-sided colonic cancer 3. The authors also addressed the issue of suboptimal concordance between contrast venography and ultrasonography for detection of lower limb deep vein thrombosis, including above knee involvement 1. A related issue is that of the strength of the negative predictive value of compression ultrasonography of lower limb veins.…”