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Is a normal computed tomography pulmonary angiography safe to rule out acute pulmonary embolism in patients with a likely clinical probability? A patient-level meta-analysis.
Thromb Haemost. 2017 07 26; 117(8):1622-1629.TH

Abstract

A normal computed tomography pulmonary angiography (CTPA) remains a controversial criterion for ruling out acute pulmonary embolism (PE) in patients with a likely clinical probability. We set out to determine the risk of VTE and fatal PE after a normal CTPA in this patient category and compare these risk to those after a normal pulmonary angiogram of 1.7 % (95 %CI 1.0-2.7 %) and 0.3 % (95 %CI 0.02-0.7 %). A patient-level meta-analysis from 4 prospective diagnostic management studies that sequentially applied the Wells rule, D-dimer tests and CTPA to consecutive patients with clinically suspected acute PE. The primary outcome was the 3-month VTE incidence after a normal CTPA. A total of 6,148 patients were included with an overall PE prevalence of 24 %. The 3-month VTE incidence in all 4,421 patients in whom PE was excluded at baseline was 1.2 % (95 %CI 0.48-2.6) and the risk of fatal PE was 0.11 % (95 %CI 0.02-0.70). In patients with a likely clinical probability the 3-month incidences of VTE and fatal PE were 2.0 % (95 %CI 1.0-4.1 %) and 0.48 % (95 %CI 0.20-1.1 %) after a normal CTPA. The 3-month incidence of VTE was 6.3 % (95 %CI 3.0-12) in patients with a Wells rule >6 points. In conclusion, this study suggests that a normal CTPA may be considered as a valid diagnostic criterion to rule out PE in the majority of patients with a likely clinical probability, although the risk of VTE is higher in subgroups such as patients with a Wells rule >6 points for which a closer follow-up should be considered.

Authors+Show Affiliations

Tom van der Hulle, MD, Department of Thrombosis and Hemostasis, Leiden University Medical Center, Albinusdreef 2, P.O Box 9600, 2300 RC, Leiden, the Netherlands, Tel.: + 31 71 526 8132, Fax: +31 71 526 6868, E-mail: t.van_der_hulle@lumc.nl.No affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article
Meta-Analysis
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

28569924

Citation

van der Hulle, Tom, et al. "Is a Normal Computed Tomography Pulmonary Angiography Safe to Rule Out Acute Pulmonary Embolism in Patients With a Likely Clinical Probability? a Patient-level Meta-analysis." Thrombosis and Haemostasis, vol. 117, no. 8, 2017, pp. 1622-1629.
van der Hulle T, van Es N, den Exter PL, et al. Is a normal computed tomography pulmonary angiography safe to rule out acute pulmonary embolism in patients with a likely clinical probability? A patient-level meta-analysis. Thromb Haemost. 2017;117(8):1622-1629.
van der Hulle, T., van Es, N., den Exter, P. L., van Es, J., Mos, I. C. M., Douma, R. A., Kruip, M. J. H. A., Hovens, M. M. C., Ten Wolde, M., Nijkeuter, M., Ten Cate, H., Kamphuisen, P. W., Büller, H. R., Huisman, M. V., & Klok, F. A. (2017). Is a normal computed tomography pulmonary angiography safe to rule out acute pulmonary embolism in patients with a likely clinical probability? A patient-level meta-analysis. Thrombosis and Haemostasis, 117(8), 1622-1629. https://doi.org/10.1160/TH17-02-0076
van der Hulle T, et al. Is a Normal Computed Tomography Pulmonary Angiography Safe to Rule Out Acute Pulmonary Embolism in Patients With a Likely Clinical Probability? a Patient-level Meta-analysis. Thromb Haemost. 2017 07 26;117(8):1622-1629. PubMed PMID: 28569924.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Is a normal computed tomography pulmonary angiography safe to rule out acute pulmonary embolism in patients with a likely clinical probability? A patient-level meta-analysis. AU - van der Hulle,Tom, AU - van Es,Nick, AU - den Exter,Paul L, AU - van Es,Josien, AU - Mos,Inge C M, AU - Douma,Renée A, AU - Kruip,Marieke J H A, AU - Hovens,Marcel M C, AU - Ten Wolde,Marije, AU - Nijkeuter,Mathilde, AU - Ten Cate,Hugo, AU - Kamphuisen,Pieter W, AU - Büller,Harry R, AU - Huisman,Menno V, AU - Klok,Frederikus A, Y1 - 2017/06/01/ PY - 2017/02/02/received PY - 2017/04/20/accepted PY - 2017/6/2/pubmed PY - 2018/5/1/medline PY - 2017/6/2/entrez KW - Pulmonary embolism KW - computed tomography KW - diagnosis KW - safety SP - 1622 EP - 1629 JF - Thrombosis and haemostasis JO - Thromb Haemost VL - 117 IS - 8 N2 - A normal computed tomography pulmonary angiography (CTPA) remains a controversial criterion for ruling out acute pulmonary embolism (PE) in patients with a likely clinical probability. We set out to determine the risk of VTE and fatal PE after a normal CTPA in this patient category and compare these risk to those after a normal pulmonary angiogram of 1.7 % (95 %CI 1.0-2.7 %) and 0.3 % (95 %CI 0.02-0.7 %). A patient-level meta-analysis from 4 prospective diagnostic management studies that sequentially applied the Wells rule, D-dimer tests and CTPA to consecutive patients with clinically suspected acute PE. The primary outcome was the 3-month VTE incidence after a normal CTPA. A total of 6,148 patients were included with an overall PE prevalence of 24 %. The 3-month VTE incidence in all 4,421 patients in whom PE was excluded at baseline was 1.2 % (95 %CI 0.48-2.6) and the risk of fatal PE was 0.11 % (95 %CI 0.02-0.70). In patients with a likely clinical probability the 3-month incidences of VTE and fatal PE were 2.0 % (95 %CI 1.0-4.1 %) and 0.48 % (95 %CI 0.20-1.1 %) after a normal CTPA. The 3-month incidence of VTE was 6.3 % (95 %CI 3.0-12) in patients with a Wells rule >6 points. In conclusion, this study suggests that a normal CTPA may be considered as a valid diagnostic criterion to rule out PE in the majority of patients with a likely clinical probability, although the risk of VTE is higher in subgroups such as patients with a Wells rule >6 points for which a closer follow-up should be considered. SN - 2567-689X UR - https://www.unboundmedicine.com/medline/citation/28569924/Is_a_normal_computed_tomography_pulmonary_angiography_safe_to_rule_out_acute_pulmonary_embolism_in_patients_with_a_likely_clinical_probability_A_patient_level_meta_analysis_ L2 - http://www.thieme-connect.com/DOI/DOI?10.1160/TH17-02-0076 DB - PRIME DP - Unbound Medicine ER -