Does This Patient Have Pulmonary Embolism?

Chunilal, Sanjeev; Eikelboom, John W.; Attia, John; Miniati, Massimo; Panju, Akbar; Simel, David L.; Ginsberg, Jeffrey S.

doi:10.1001/jama.290.21.2849

Cited by 158 publications

(90 citation statements)

References 49 publications

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“…18 -20,26,27 Although other risk indices exist, the Wells score has been shown to have predictive powers equal to other algorithms and to clinicians; implicit assessments. 28,29 In our cohort, 35.1% of patients with a high pretest probability were diagnosed with PE; although this was lower than that in the initial Wells cohort, 18 it was very similar to a subsequent validation study using the Wells algorithm, in which the prevalence of PE in patients with high pretest probability was 37.5%. 27 Plasma D-dimer testing is not routinely used at our hospitals, but it is a component of some CTPAbased diagnostic algorithms.…”

Section: Discussionsupporting

confidence: 71%

Impact of reliance on CT pulmonary angiography on diagnosis of pulmonary embolism: A Bayesian analysis

Ranji

Shojania

Trowbridge

et al. 2006

Journal of Hospital Medicine

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BACKGROUNDSpiral computed tomographic pulmonary angiography (CTPA) has become the primary test used to investigate suspected pulmonary embolism (PE) at many institutions, despite uncertainty regarding its sensitivity and specificity. Although CTPA‐based diagnostic algorithms focus on minimizing the false‐negative rate, we hypothesized that increasing use of CTPA also might lead to false‐positive diagnoses.OBJECTIVEDetermine the frequency of possible false‐positive diagnoses of PE when CTPA is the primary diagnostic test.DESIGNRetrospective cohort study.SETTINGTwo academic teaching hospitals.PARTICIPANTS322 patients with suspected PE evaluated with CTPA.MEASUREMENTSWe used a validated prediction rule to determine the pretest probability of PE in each patient. We combined these pretest probabilities with published estimates of CTPA test characteristics to generate expected posttest probabilities of PE. We compared these posttest probabilities to actual treatment decisions to determine the rate of false‐positive diagnoses of PE.RESULTSAmong 322 patients investigated for PE, 37 (12%) had high pretest probability, 101 (32%) moderate, and 184 (57%) low. CT scans were interpreted as positive for PE in 57 patients (17.8%). Regardless of the pretest probability of PE, 96.5% of patients with a positive CTPA were treated with anticoagulants. Even under an optimistic assumption of CTPA test characteristics, as many as 25.4% of these patients may have been treated unnecessarily as a result of a false‐positive diagnosis. Most of these patients had a low pretest probability of PE.CONCLUSIONSFailure to utilize Bayesian reasoning when interpreting CTPA may lead to false‐positive diagnoses of pulmonary embolism in a substantial proportion of patients. Journal of Hospital Medicine 2006;1:81–87. © 2006 Society of Hospital Medicine

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Section: Discussionsupporting

confidence: 71%

Impact of reliance on CT pulmonary angiography on diagnosis of pulmonary embolism: A Bayesian analysis

Ranji

Shojania

Trowbridge

et al. 2006

Journal of Hospital Medicine

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“…Atualmente, tendo em vista a variabilidade da experiência pessoal no atendimento de pacientes com TEP, recomenda-se a utilização de escores de predição clínica validados. (15) Entre eles, o mais estudado e aplicável, tanto em pacientes que chegam à emergência quanto naqueles já hospitalizados, é o Escore Canadense (de Wells). Apesar de inicialmente dividido em três níveis, estudos mais recentes têm dicotomizado o escore (TEP improvável: escore ≤ 4; ou TEP provável: escore > 4) na abordagem inicial, simplificando as decisões.…”

Section: Pacientes Clinicamente Estáveisunclassified

Algoritmos de diagnóstico

2010

J. bras. pneumol.

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“…3,12,31,32 These models provide point values that quantify the contributions of the various components of history, physical examination, and laboratory results, and how those components contribute to establishing a diagnosis, prognosis, or likely response to treatment in an individual patient. The clinical prediction rules attempt to categorize each suspected patient with pulmonary embolism into a low-, moderate-, or high-risk group, based on subjective symptoms, objective signs, or a combination thereof.…”

Section: Differential Diagnosismentioning

confidence: 99%

“…12,13,17,26 The accuracy of making a clinical diagnosis of pulmonary embolism varies widely with clinical suspicion predicting pulmonary embolism from 8% to 91% of the time, and clinical prediction rules reportedly accurate from 3% to 98% of the time, though prediction rules can be used by less-experienced clinicians. 3 The large discrepancies are further partially attributed to the fact that many patients are asymptomatic and have no clinical findings. 6,22 When the suspicion of a pulmonary embolism is present, based on the assessment of the patient's risk 14 (ie, physical therapy screening exami- nation and/or Wells score), the patient must be referred for medical evaluation to avoid placing the health of the patient at further risk.…”

Section: Differential Diagnosismentioning

confidence: 99%

Pulmonary Emboli: The Differential Diagnosis Dilemma

Young

Flynn²

2005

J Orthop Sports Phys Ther

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Pulmonary embolism is a rare but serious medical condition, with an estimated mortality of 5% to 20%. Many patients receiving physical therapy may be at risk for developing pulmonary embolism, especially after periods of immobilization or surgery. Patients presenting with dyspnea, chest pain, or tachypnea, particularly after trauma or surgery, have an increased likelihood of pulmonary embolism. Clinical prediction rules have been developed, which can aid the practitioners in assessing the risk a patient has for developing pulmonary embolism. The present clinical commentary discusses the existing evidence for screening patients for pulmonary embolism. To illustrate the importance of the screening examination, a patient is presented who was referred to physical therapy 5 days after cervical discectomy and fusion. This patient was subsequently referred for medical evaluation and a confirmatory diagnosis of pulmonary embolism. J Orthop Sports Phys Ther 2005;35:637-644. Key Words: chest pain, dyspnea, lungs, screening, thromboembolism P ulmonary embolism occurs when a portion of the pulmonary vessels are occluded, whether by blood clot (deep vein thrombosis), air, fat, or bone marrow. 9,15,22 Deep vein thromboses (DVTs) in the lower extremity are commonly associated with pulmonary embolism, with up to 70% of patients with pulmonary embolism having evidence of leg DVT.6,22 DVT may also form in the pelvis or upper extremity. 13,26 A DVT that develops into a pulmonary embolism is classified as a thromboembolism.11 There are approximately 650 000 cases of pulmonary embolism annually in the United States, 9 with an estimated occurrence rate of 0.23% in a tertiary care hospital. 28 The incidence of pulmonary embolism increases with age (r = 0.94), with females having a significantly greater incidence than males over the age of 50 years. 28 The mortality rate attributed to pulmonary embolism is unknown, but estimated to be between 5% and 20%. 22Physical therapists frequently manage patients who are at increased risk for pulmonary embolism. Approximately 1 in 20 (5%) patients undergoing hip arthroplasty will develop a pulmonary embolism, with 50% of these being fatal.7,22 A 5.6% risk of nonfatal, symptomatic pulmonar y embolism has been reported following total knee arthroplasty, 16 with an estimated risk of death occurring in 0.03% to

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Does This Patient Have Pulmonary Embolism?

Cited by 158 publications

References 49 publications

Impact of reliance on CT pulmonary angiography on diagnosis of pulmonary embolism: A Bayesian analysis

Impact of reliance on CT pulmonary angiography on diagnosis of pulmonary embolism: A Bayesian analysis

Algoritmos de diagnóstico

Pulmonary Emboli: The Differential Diagnosis Dilemma

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