Pulmonary Embolism Diagnosis and Mortality With Pulmonary CT Angiography Versus Ventilation-Perfusion Scintigraphy: Evidence of Overdiagnosis With CT?

Sheh, Steven H.; Bellin, Eran; Freeman, Katherine; Haramati, Linda B.

doi:10.2214/ajr.11.6426

Cited by 58 publications

(36 citation statements)

References 41 publications

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“…Such data led to the author's conclusion 'CTPA utilisation has risen with no corresponding change in diagnostic yield resulting in an increase in PE detection. There is a concurrent rise in the likelihood of diagnosing a less clinically severe spectrum of PE's' [18].…”

Section: Test Bolus Vs Bolus Tracking Does Not Increase the Hu Valmentioning

confidence: 99%

“…Sheh et al [18] similarly concluded that the use of CT in diagnosis of PE has led to an increased rate of detection of a 'less fatal spectrum of pulmonary embolic disease'. The 7 year study conducted in an urban academic hospital raises the substantiated evidence once again outlining how the shift from previous imaging methods of ventilation/perfusion (V/Q scintigraphy) and pulmonary arteriography to CT alone has led to such an outcome.…”

Section: Test Bolus Vs Bolus Tracking Does Not Increase the Hu Valmentioning

confidence: 99%

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A Comparison of 100 kVp Versus 120 kVp CTPA Acquisition with Direct Comparisons of Test Bolus and Bolus Tracking at Same and Different Voltages in a Multidetector 64 Slice CT Scanner

Bowden

Kiely

et al. 2017

IJRRT

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This study focused on several aspects of CTPA (Computed Tomography Pulmonary Angiogram) imaging. Primarily to reinforce and substantiate previous research done in the fields of low voltage CTPA acquisition by analysing data obtained during study and seeing what the resultant reduction in kV (Kilovoltage) has on attenuation levels in the pulmonary vessels and whether the decrease in signal intensity adversely affects image quality to any significant degree. To compare bolus tracking and test bolus in CTPA imaging.150 patients were involved and imaged between January 2015 and August 2015. 50 pts were scanned at 100kVp with Test Bolus (Group A). 50 pts were scanned at 120kVp using Bolus Tracking (Group B). 50 patients were scanned at 120kVp using Test Bolus (Control Group). Vascular enhancement, Signal to Noise Ratio (SNR), Contrast to Noise Ratio (CNR), image noise, radiation dosimetry, and contrast use were recorded. Subjective image quality was assessed by two blinded radiologists. All injections took place at a rate of 4ml/sec through an 18 gauge bore cannula sited at the antecubital fossa. Flow rate was kept constant at 4ml/sec throughout the procedure. At both 100 and 120kVp, the injected iodine concentration was the same.The reduction in tube potential resulted in an increase in mean attenuation measured in Hounsfield Units (HU) in the main pulmonary of 25.1% (307.46 to 410.48). Despite a 30% increase in image noise at 100kV there was no significant impact on SNR or CNR values. Radiation dose was considerably decreased by 40% at 100kV with no noteworthy difference in image quality in the images assessed. Use of Test Bolus decreased contrast use by over 25% from the standard amount of 80mls but which had no effect on the attenuation values.

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Section: Test Bolus Vs Bolus Tracking Does Not Increase the Hu Valmentioning

confidence: 99%

Section: Test Bolus Vs Bolus Tracking Does Not Increase the Hu Valmentioning

confidence: 99%

A Comparison of 100 kVp Versus 120 kVp CTPA Acquisition with Direct Comparisons of Test Bolus and Bolus Tracking at Same and Different Voltages in a Multidetector 64 Slice CT Scanner

Bowden

Kiely

et al. 2017

IJRRT

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“…However, with increasing number of detector rows the rate of isolated subsegmental PE detected by CT has increased only moderately from 4.7 % to 9.4 % (single versus multislice) [20], and only in younger patients to 16 % [21]. Also the shift from less sensitive planar V/P scintigraphy with PIOPED interpretation to more sensitive CTPA can be held responsible for the increased incidence of PE [16]. Authors of the same working group suggest that V/P planar and V/P SPECT and CTPA have similar sensitivities, and thus have a similar impact on outcomes [22].…”

mentioning

confidence: 97%

“…From 2000 to 2007 the case-fatality index in the USA decreased from 5.7 % to 3.3 %. In the same period the incidence of PE increased from 0.69 to 0.91 per 100 admissions [16]. Since 1998, when multidetector row CTPA was introduced in the USA, the incidence of diagnosed PE has been steadily increasing.…”

mentioning

confidence: 99%

Perfusion SPECT in patients with suspected pulmonary embolism: how much sensitivity is needed to keep patients alive?

Schuemichen

2013

Eur J Nucl Med Mol Imaging

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Combined use of ventilation (V) and perfusion (P) scintigraphy for the diagnosis of acute and chronic thromboembolic pulmonary embolism (PE) has been well established for nearly 50 years, and is also anchored in the current European guidelines [1,2]. The intention in using this technique is to differentiate between local V/P mismatch associated with embolic disease and local V/P match related to obstructive airway disease. This functional approach to the diagnosis of PE is needed mostly in elderly patients, since the incidence of obstructive airway disease increases with age. With Ponly scintigraphy the rate of false-positive findings increases to an unacceptable 47 % even with SPECT/CT [3]. Despite well-documented advantages, V scintigraphy has not become popular in many European countries for various reasons: availability (Italy), expense, fear of radioactive contamination, and lack of quality control (Germany).In 2005, P-only scintigraphy was performed in 89 % of all lung examinations in Italy, in 72.4 % in Germany, in 44.1 % in Spain, in 21.3 % in the UK, and in only 12.4 % in France [4]. Proof or exclusion of PE was intended in most of these studies. Two years later, following the success of CT pulmonary angiography (CTPA), the number of V scintigraphies in Germany increased by 25 %, but lung examinations went down by 37 %. In Italy, morphological attributes (PISA-PED criteria) as a substitute for V scintigraphy have been added to reduce false-positive results from P-only planar scintigraphy. Single or multiple wedge-shaped P defects, with or without matching chest roentgenographic abnormalities, are reported as PE-positive. Wedge-shaped areas of overperfusion usually coexist. P defects other than wedgeshaped are PE-negative. With pulmonary angiography as reference, the P lung scan has been shown to have a sensitivity of 92 % and a specificity of 87 % in the diagnosis of PE [5]. Compared to CTPA and also V/P planar scintigraphy with PIOPED II interpretation together with chest radiography, the sensitivity of P-only planar scintigraphy with PISA-PED interpretation is somewhat below 90 %, but diagnostic accuracy is remarkably similar [6]. Applying V/P SPECT as reference, with interpretation criteria of the European guidelines, the sensitivity of P-only SPECT with PISA-PED interpretation criteria rose to an acceptable 90 %, and specificity to a fantastic 98 %. Segmental pneumonia was mentioned as a cause of false-positive findings, which could have been identified on a chest radiograph or more easily by SPECT/CT. These very promising results may be misinterpreted as an invitation to get rid of unpopular V scintigraphy.From our own experience it seems reasonable that the appearance of secondary perfusion defects in chronic obstructive airway disease (COPD) at the lobar and segmental level may be irregular and does not follow the lobar and segmental anatomy with a frequency that, if need be, is sufficient for diagnosis of PE. However, perfusion defects at the subsegmental level are mostly not distinguishable in ...

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“…In addition, increased use of CT pulmonary angiography (CTPA), with a corresponding increase in PE diagnoses, has raised concerns about overdiagnosis (the detection of minimally clinically significant disease, including false-positives). [4][5][6][7] Overtreatment with anticoagulant therapy imposes significant risk of hemorrhage, including intracranial hemorrhage (ICH), even with short duration of treatment. A large registry found that 15,238 venous thromboembolism patients treated with anticoagulation had a 3-month rate of major bleeding of 1.64% (95% confidence interval [CI] = 1.45% to 1.86%), including 0.2% (95% CI = 0.14% to 0.30%) with ICH.…”

mentioning

confidence: 99%

Cost‐effectiveness of Quantitative Pretest Probability Intended to Reduce Unnecessary Medical Radiation Exposure in Emergency Department Patients With Chest Pain and Dyspnea

Troyer

Jones

Shapiro

et al. 2015

Academic Emergency Medicine

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Objectives: Quantitative pretest probability (qPTP) incorporated into a decision support tool with advice can reduce unnecessary diagnostic testing among patients with symptoms suggestive of acute coronary syndrome (ACS) and pulmonary embolism (PE), reducing 30-day costs without an increase in 90-day adverse outcomes. This study estimates long-term (beyond 90-day) costs and outcomes associated with qPTP. The authors hypothesized that qPTP reduces lifetime costs and improves outcomes in low-risk patients with symptoms suggestive of ACS and PE.Methods: This was a cost-effectiveness analysis of a multicenter, randomized controlled trial of adult emergency patients with dyspnea and chest pain, in which a clinician encountering a low-risk patient with symptoms suggestive of ACS or PE conducted either the intervention (qPTP for ACS and PE with advice) or the sham (no qPTP and no advice). Effect of the intervention over a patient's lifetime was assessed using a Markov microsimulation model. Short-term costs and outcomes were from the trial; long-term outcomes and costs were from the literature. Outcomes included lifetime transition to PE, ACS, and intracranial hemorrhage (ICH); mortality from cancer, ICH, PE, ACS, renal failure, and ischemic stroke; quality-adjusted life-years (QALYs); and total medical costs compared between simulated intervention and sham groups.Results: Markov microsimulation for a 40-year-old patient receiving qPTP found lifetime cost savings of $497 for women and $528 for men, associated with small gains in QALYs (2 and 6 days, respectively) and lower rates of cancer mortality in both sexes, but a reduction in ICH only in males. Sensitivity analysis for patients aged 60 years predicted that qPTP would continue to save costs and also reduce mortality from both ICH and cancer. Use of qPTP significantly reduced the lifetime probability of PE diagnosis, with lower probability of death from PE in both sexes aged 40 to 60 years. However, use of qPTP reduced the rate of ACS diagnosis and death from ACS at age 40, but increased the death rate from ACS at age 60 for both sexes.

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Pulmonary Embolism Diagnosis and Mortality With Pulmonary CT Angiography Versus Ventilation-Perfusion Scintigraphy: Evidence of Overdiagnosis With CT?

Cited by 58 publications

References 41 publications

A Comparison of 100 kVp Versus 120 kVp CTPA Acquisition with Direct Comparisons of Test Bolus and Bolus Tracking at Same and Different Voltages in a Multidetector 64 Slice CT Scanner

A Comparison of 100 kVp Versus 120 kVp CTPA Acquisition with Direct Comparisons of Test Bolus and Bolus Tracking at Same and Different Voltages in a Multidetector 64 Slice CT Scanner

Perfusion SPECT in patients with suspected pulmonary embolism: how much sensitivity is needed to keep patients alive?

Cost‐effectiveness of Quantitative Pretest Probability Intended to Reduce Unnecessary Medical Radiation Exposure in Emergency Department Patients With Chest Pain and Dyspnea

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