Diagnosis of Pulmonary Embolism In Outpatients by Sequential Noninvasive Tools

ABSTRACT

Considerable progress has been made in pulmonary embolism (PE) diagnosis during the last 10 years. New, noninvasive tools such as D-dimer measurement and lower limb venous compression ultrasonography have been introduced as diagnostic strategies. Clinical evaluation of the likelihood of PE has been rehabilitated and has proven to be accurate and useful. The interpretation of lung scan results has become more standardized and clear to clinicians. Finally, two diagnostic strategies have been validated in large scale outcome studies. Both rely on a sequential combination of the aforementioned instruments and have safely treated more than 90% of patients without use of pulmonary angiography. The 3-month venous thromboembolic risk in patients in whom PE was ruled out and, hence, who did not undergo anticoagulation was less than 1% in both studies. In the absence of a formal comparison of their respective cost-effectiveness, choosing between these strategies rests on local preferences or logistics. Finally, spiral computed tomography (CT) seems promising and might modify the diagnostic work-up of PE in the near future. However, it is insufficiently validated, and its place in a rational diagnostic algorithm is not defined.

KEYWORD

Pulmonary embolism - fibrin fibrinogen degradation products - enzyme-linked immunosorbent assay - lung/radionuclide imaging - ultrasonography - spiral CT scan

REFERENCES

• 1 Hull R D, Hirsh J, Carter C J. Diagnostic value of ventilation-perfusion lung scanning in patients with suspected pulmonary embolism.  Chest . 1985;  88 819-828
• 2 Hull R D, Raskob G E, Ginsberg J S. A noninvasive strategy for the treatment of patients with suspected pulmonary embolism.  Arch Intern Med . 1994;  154 289-297
• 3 The PIOPED Investigators. Value of the ventilation-perfusion scan in acute pulmonary embolism.  JAMA . 1990;  263 2753-2759
• 4 Stein P D, Athanasoulis C, Alavi A. Complications and validity of pulmonary angiography in acute pulmonary embolism.  Circulation . 1992;  85 462-468
• 5 Sostman H D, Ravin C E, Sullivan D C. Use of pulmonary angiography for suspected pulmonary embolism: Influence of scintigraphic diagnosis.  Am J Roentgen . 1982;  139 673-677
• 6 Bounameaux H, de Moerloose P, Perrier A, Miron M J. D-dimer testing in suspected venous thromboembolism: An update.  QJM . 1997;  90 437-442
• 7 Perrier A, Bounameaux H. Ultrasonography of leg veins in patients suspected of having pulmonary embolism.  Ann Intern Med . 1998;  128 243-251
• 8 Turkstra F, Kuijer P MM, van Beek J R E. Diagnostic utility of ultrasonography of leg veins in patients suspected of having pulmonary embolism.  Ann Intern Med . 1997;  126 775-781
• 9 Wells P S, Ginsberg J S, Anderson D R. Use of a clinical model for safe management of patients with suspected pulmonary embolism.  Ann Intern Med . 1998;  129 997-1005
• 10 Perrier A, Bounameaux H, Morabia A. Diagnosis of pulmonary embolism by a decision analysis-based strategy including clinical probability, D-dimer levels, and ultrasonography: A management study.  Arch Intern Med . 1996;  156 531-536
• 11 Perrier A, Desmarais S, Miron M J. Noninvasive diagnosis of venous thromboembolism.  Lancet . 1999;  353 190-195
• 12 Rémy-Jardin M, Remy J, Deschildre F. Diagnosis of pulmonary embolism with spiral CT: Comparison with pulmonary angiography and scintigraphy.  Radiology . 1996;  200 699-706
• 13 Rémy-Jardin M, Rémy J, Wattinne L, Giraud F. Central pulmonary thromboembolism: Diagnosis with spiral volumetric CT with the single-breath-holds technique. Comparison with pulmonary angiography.  Radiology . 1992;  185 381-387
• 14 van Rossum B A, Pattynama P MT, Tjin A. Pulmonary embolism: Validation of spiral CT angiography in 149 patients.  Radiology . 1996;  201 23-28
• 15 Stein P D, Terrin M L, Hales C A. Clinical, laboratory, roentgenographic, and electrocardiographic findings in patients with acute pulmonary embolism and no pre-existing cardiac or pulmonary disease.  Chest . 1991;  100 598-603
• 16 Righini M, Goehring C, Bounameaux H, Perrier A. Influence of age on performances of common diagnostic tests in suspected pulmonary embolism.  Am J Med . 2000;  109 357-361
• 17 Perrier A, Miron M J, Desmarais S. Combining clinical probability and lung scan in suspected pulmonary embolism.  Arch Intern Med . 2000;  160 512-516
• 18 Miniati M, Prediletto R, Formichi B. Accuracy of clinical assessment in the diagnosis of pulmonary embolism.  Am J Respir Crit Care Med . 1999;  159 864-871
• 19 Wasson J H, Sox H C. Clinical prediction rules. Have they come of age?.  JAMA . 1996;  275 641-642
• 20 Wyatt J C, Atman D G. Prognostic models: Clinically useful or quickly forgotten?.  BMJ . 1995;  311 1539-1541
• 21 The PISA-PED Investigators. Value of perfusion lung scan in the diagnosis of pulmonary embolism: Results of the prospective study of acute pulmonary embolism diagnosis (PISA-PED).  Am J Respir Crit Care Med . 1996;  154 1387-1393
• 22 Gottschalk A, Sostman H D, Coleman R E. Ventilation-perfusion scintigraphy in the PIOPED study. Part II. Evaluation of scintigraphic criteria and interpretations.  J Nucl Med . 1993;  34 1119-1126
• 23 Perrier A, Desmarais S, Goehring C. D-dimer testing for suspected pulmonary embolism in outpatients.  Am J Respir Crit Care Med . 1997;  156 492-496
• 24 Miron M J, Perrier A, Bounameaux H. Contribution of noninvasive evaluation to the diagnosis of pulmonary embolism in hospitalized patients.  Eur Respir J . 1999;  13 1365-1370
• 25 Ginsberg J S, Wells P S, Kearon C. Sensitivity and specificity of a rapid whole-blood assay for D-dimer in the diagnosis of pulmonary embolism.  Ann Intern Med . 1998;  129 1006-1011
• 26 Perrier A, Buswell L, Bounameaux H. Cost-effectiveness of noninvasive diagnostic aids in suspected pulmonary embolism.  Arch Intern Med . 1997;  157 2309-2316
• 27 Moser K M, Fedullo P F, Littejohn J K, Crawford R. Frequent asymptomatic pulmonary embolism in patients with deep venous thrombosis.  JAMA . 1994;  271 223-225
• 28 Wells P S, Lensing A WA, Davidson B L, Prins M H, Hirsh J. Accuracy of ultrasound for the diagnosis of deep venous thrombosis in asymptomatic patients after orthopedic surgery.  Ann Intern Med . 1995;  122 47-53
• 29 Rémy-Jardin M, Rémy J, Artaud D, Deschildre F, Duhamel A. Peripheral pulmonary arteries: Optimization of the spiral CT acquisition protocol.  Radiology . 1997;  204 157-163
• 30 Beigelmann C, Chartrand-Lefebvre C, Howarth N, Grenier P. Pitfalls in the diagnosis of pulmonary embolism with helical CT angiography.  Am J Roentgen . 1998;  171 579-585
• 31 Stein P D, Henry J W. Prevalence of acute pulmonary embolism in central and subsegmental pulmonary arteries and relation to probability interpretation of ventilation/perfusion lung scans.  Chest . 1997;  111 1246-1248
• 32 Ferretti G R, Bosson J L, Bufaz P D. Acute pulmonary embolism: role of helical CT in 164 patients with intermediate probability at ventilation-perfusion scintigraphy and normal results at duplex US of the legs.  Radiology . 1997;  205 453-458
• 33 Bounameaux H, de Moerloose P, Perrier A, Reber G. Plasma measurement of D-dimer as diagnostic aid in suspected venous thromboembolism: An overview.  Thromb Haemost . 1994;  71 1-6
• 34 de Moerloose P, Desmarais S, Bounameaux H. Contribution of a new, rapid, individual and quantitative automated D-dimer ELISA to exclude pulmonary embolism.  Thromb Haemost . 1996;  75 11-13
• 35 Oger E, Leroyer C, Bressollette L. Evaluation of a new, rapid, and quantitative D-Dimer test in patients with suspected pulmonary embolism.  Am J Respir Crit Care Med . 1998;  158 65-70
• 36 Reber G, Bounameaux H, Perrier A, de Moerloose P. Performances of a new, rapid and automated microlatex D-dimer assay for the exclusion of pulmonary embolism in symptomatic outpatients.  Thromb Haemost . 1998;  80 719-720
• 37 Ginsberg J S, Wells P S, Brill-Edwards P E. Application of a novel and rapid whole blood assay for D-Dimer in patients with clinically suspected pulmonary embolism.  Thromb Haemost . 1995;  73 379-386
• 38 Turkstra F, van Beek R J, ten Cate W J, Büller H R. Reliable rapid blood test for the exclusion of venous thromboembolism in symptomatic outpatients.  Thromb Haemost . 1996;  76 9-11
• 39 Killewich L A, Nunnelee J D, Auer A I. Value of lower extremity venous duplex examination in the diagnosis of pulmonary embolism.  J Vasc Surg . 1993;  17 934-938
• 40 Smith L L, Conrad I, Sirr S. Pulmonary embolism: Confirmation with venous duplex US as adjunct to lung scanning.  Radiology . 1994;  191 143-147
• 41 Beecham R P, Dorfman G S, Cronan J J. Is bilateral lower extremity compression sonography useful and cost-effective in the evaluation of suspected pulmonary embolism?.  Am J Roentgen . 1993;  161 1289-1292
• 42 Teigen C L, Maus T P, Sheedy II F P. Pulmonary embolism: Diagnosis with contrast-enhanced electron-beam CT and comparison with pulmonary angiography.  Radiology . 1995;  194 313-319
• 43 Goodman L R, Curtin J J, Mewissen M W. Detection of pulmonary embolism in patients with unresolved clinical and scintigraphic diagnosis: Helical CT versus angiography.  Am J Roentgen . 1995;  164 1369-1374
• 44 van Rossum B A, Treurniet F E, Kieft G J, Smith S J, Schepers-Bok R. Role of spiral volumetric computed tomographic scanning in the assessment of patients with clinical suspicion of pulmonary embolism and an abnormal ventilation/perfusion lung scan.  Thorax . 1996;  51 23-28
• 45 Mayo J R, Rémy-Jardin M, Muller N L. Pulmonary embolism: Prospective comparison of spiral CT with ventilation-perfusion scintigraphy.  Radiology . 1997;  205 447-452
• 46 Garg K, Welsh C H, Feyerabend A J. Pulmonary embolism: Diagnosis with spiral CT and ventilation-perfusion scanning-correlation with pulmonary angiographic results or clinical outcome.  Radiology . 1998;  208 201-208
• 47 Kim K I, Muller N L, Mayo J R. Clinically suspected pulmonary embolism: Utility of spiral CT.  Radiology . 1999;  210 693-697