Heightened clinical suspicion of pulmonary embolism and disregard of the <scp>d</scp>‐dimer assay: a contemporary trend in an era of increased access to computed tomography pulmonary angiogram?

IntroductionOveruse of CT Pulmonary Angiograms (CTPA) for diagnosing pulmonary embolism (PE), particularly in Emergency Departments (ED), is considered problematic. Marked variations in positive CTPA rates are reported, with American 4–10% yields driving most concerns. Higher resolution CTPA may increase sub-segmental PE (SSPE) diagnoses, which may be up to 40% false positive. Excessive use and false positives could increase harm vs. benefit. These issues have not been systematically examined outside America.AimsTo describe current yield variation and CTPA utilisation in Australasian ED, exploring potential factors correlated with variation.MethodsA retrospective multi-centre review of consecutive ED-ordered CTPA using standard radiology reports. ED CTPA report data were inputted onto preformatted data-sheets. The primary outcome was site level yield, analysed both intra-site and against a nominated 15.3% yield. Factors potentially associated with yield were assessed for correlation.ResultsFourteen radiology departments (15 ED) provided 7077 CTPA data (94% ≥64-slice CT); PE were reported in 1028 (yield 14.6% (95%CI 13.8–15.4%; range 9.3–25.3%; site variation p <0.0001) with four sites significantly below and one above the 15.3% target. Admissions, CTPA usage, PE diagnosis rates and size of PE were uncorrelated with yield. Large PE (≥lobar) were 55% (CI: 52.1–58.2%) and SSPE 8.8% (CI: 7.1–10.5%) of positive scans. CTPA usage (0.2–1.5% adult attendances) was correlated (p<0.006) with PE diagnosis but not SSPE: large PE proportions.Discussion/ ConclusionsWe found significant intra-site CTPA yield variation within Australasia. Yield was not clearly correlated with CTPA usage or increased small PE rates. Both SSPE and large PE rates were similar to higher yield historical cohorts. CTPA use was considerably below USA 2.5–3% rates. Higher CTPA utilisation was positively correlated with PE diagnoses, but without evidence of increased proportions of small PE. This suggests that increased diagnoses seem to be of clinically relevant sized PE.

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“…[4,9,21–25] Data from Australasia is very limited in both quality and quantity, with yields reported from 6% to 14%. [26–28]…”

Section: Introductionmentioning

confidence: 99%

RESPECT-ED: Rates of Pulmonary Emboli (PE) and Sub-Segmental PE with Modern Computed Tomographic Pulmonary Angiograms in Emergency Departments: A Multi-Center Observational Study Finds Significant Yield Variation, Uncorrelated with Use or Small PE Rates

et al. 2016

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“…The D-dimer assay stands as a highly sensitive test frequently employed in the evaluation of PE. This test quantifies monoclonal antibodies targeting D-dimer, a byproduct of fibrinolysis, thus reflecting coagulation activity [ 4 ]. Initially, D-dimer levels rise during fibrin clot formation, gradually diminishing as clot organization and adherence commence.…”

Section: Discussionmentioning

confidence: 99%

“…Notably, the D-dimer test has a relatively brief half-life of four to six hours but remains elevated for about seven days post-clot formation. Nevertheless, a negative D-dimer assay is generally deemed reliable, particularly in low- and moderate-risk patients [ 4 ].…”

Section: Discussionmentioning

confidence: 99%

Low Risk Meets High Stakes: Unraveling the Mystery of Low D-dimer Pulmonary Embolism

Kasanga,

Khashan,

Salik

et al. 2023

Cureus

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Pulmonary embolisms (PEs) are potentially life-threatening emergencies that carry significant morbidity and mortality. Advances in treatment options and the safety of existing procedures have effectively reduced the long-term and short-term effects of the condition. Therefore, it is important to make an early diagnosis so that treatment options can be thoroughly explored. The D-dimer is an important tool in the early diagnosis of PEs. It is especially useful in ruling out the diagnosis in patients with a low to moderate suspicion of the disease. We present a case of a 22-year-old male who presented with exertional dyspnea, congestion, and rhinorrhea for one day and was noted to have persistent hypoxia and tachycardia. The influenza test was positive, and he was started on oseltamivir. Due to persistent hypoxia, a CT pulmonary angiogram was ordered and revealed filling defects in the left lower lobe segmental vessels suggestive of PE, as well as multifocal multilobar bilateral ground-glass opacities. He was initially treated with a heparin drip and subsequently switched to eliquis. After a significant improvement in his hypoxia, he was discharged home for outpatient follow-up, including a hypercoagulable workup. This case demonstrates that despite the usefulness of the D-dimer as a diagnostic tool for PEs, it cannot solely or fully replace the full gamut of screening tools used to determine the risk of PE. Although rare, false-negative scores do occur; therefore, the tool should always be used in conjunction with other scoring systems, physician gestalt, and within the specific clinical context.

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“…In summary, this audit had proven that poor utilization of pretest risk assessment tool d resulted unnecessary use of CTPA that caused harm for some patients. To minimize this problem, we strongly recommend introducing educational interventions such as seminars as well as devising algorithms targeting clinicians who request imaging without compromising patient safety [23,24]. Guidelines such as these are beneficial to clinicians as they aid in overcoming defensive practice and fear of missing the diagnosis [19].…”

Section: Discussionmentioning

confidence: 99%

The patterns of ordering Computed Tomography Pulmonary Angiogram (CTPA) for diagnosis of pulmonary embolism (PE) in a rural health setting

Alawi¹,

Srinivasan²,

Khan³

et al. 2018

Radiol Diagn Imaging

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Background: Pulmonary embolism (PE) is a life-threatening condition with overall mortality of up to 20 % when left untreated. CTPA is the preferred investigation for diagnosis of PE for patients with normal kidney function. Several studies showed this test is being over employed without using available predictive tools i.e. Wells score, Modified Geneva score & D-Dimer Methodology: A retrospective review of patients' records who had CTPA for suspected pulmonary embolism from the period of 1st March 2015 to 28th Feb 2016. Patient's demographics and components of different scoring system were obtained by manual review of patient's electronic records.Result: A total of 249 CTPAs were done during this study period. In term of patient demographics, median age was 63 years and 48.6 % of patients were females. PE was diagnosed in 34 (13.7%) patients. Only 196 (76.6%) patients had a CXR as an initial investigation. Acute kidney injury was noted in 23 (14.0%) patients post CTPA.Revised Geneva score was calculated for all patients who had CTP for PE, only 10 (4 %) patients had a high probability on Revised Geneva score (score >11). Wells score could not be accurately calculated due to the retrospective nature of the study. Conclusion:The diagnostic yield of CTPA with a positive result for pulmonary embolism was 13.7%, which is below the recommended standards by the Royal College of Radiology (UK) (15.4% to 37.4%). Also, these findings were noted to be inferior compared with a similar study done in an Australian hospital. These findings may be attributed to the poor utilization of risk assessment tools (Geneva, Wells and D-Dimer) and not performing simple chest X-ray prior to CTPA. A protocol to request CTPAs is needed which is suited to the regional settings to avoid unnecessary CTPAs and its complications.

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Heightened clinical suspicion of pulmonary embolism and disregard of the d‐dimer assay: a contemporary trend in an era of increased access to computed tomography pulmonary angiogram?

Cited by 6 publications

References 20 publications

RESPECT-ED: Rates of Pulmonary Emboli (PE) and Sub-Segmental PE with Modern Computed Tomographic Pulmonary Angiograms in Emergency Departments: A Multi-Center Observational Study Finds Significant Yield Variation, Uncorrelated with Use or Small PE Rates

RESPECT-ED: Rates of Pulmonary Emboli (PE) and Sub-Segmental PE with Modern Computed Tomographic Pulmonary Angiograms in Emergency Departments: A Multi-Center Observational Study Finds Significant Yield Variation, Uncorrelated with Use or Small PE Rates

Low Risk Meets High Stakes: Unraveling the Mystery of Low D-dimer Pulmonary Embolism

The patterns of ordering Computed Tomography Pulmonary Angiogram (CTPA) for diagnosis of pulmonary embolism (PE) in a rural health setting

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