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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(5):531-6AI

Abstract

BACKGROUND

Assessment of the clinical probability of pulmonary emboli sm, plasma D-dimer measurement, and lower-limb venous compression ultrasonography have all been advocated in the workup of suspected pulmonary embolism, to minimize the requirement for pulmonary angiography in patients with nondiagnostic lung scans. However, their contribution has not been assessed prospectively.

METHODS

Three hundred eight consecutive patients who came to the emergency department with suspected pulmonary embolism were managed according to a diagnostic protocol that included clinical probability assessment, lung scan, and sequential noninvasive tests: plasma D-dimer measurement by enzyme-linked immunosorbent assay (a concentration <500 microgram/L ruled out pulmonary embolism) and lower-limb B-mode venous compression ultrasonography (a positive finding was diagnostic of venous thromboembolism). Patients without pulmonary embolism according to the diagnostic workup did not receive anticoagulant treatment. The safety of this approach was assessed by a 6-month follow-up.

RESULTS

of the 308 patients, 106 (34%) had a diagnostic lung scan (normal in 43 and high probability in 63). For the remaining 202 patients, noninvasive workup was diagnostic in 125 (62%). Pulmonary embolism was ruled out by a low clinical probability and a nondiagnostic scan in 48 patients and a D-dimer level less than 500 microgram/L in 53; pulmonary embolism was established by a high clinical probability and a nondiagnostic scan in seven patients and by a finding of a deep vein thrombosis on ultrasonography in 17. Therefore, only 77 of these 202 patients underwent pulmonary angiography (negative in 55; positive in 22). At 6-month follow-up (completed for 99.4% of the study population), only two of the 199 patients in whom the diagnostic protocol had ruled out pulmonary embolism (1.0% [95% confidence interval, 0.1 to 3.6]) had a thromboembolic event (pulmonary embolism, one; deep vein thrombosis, one).

CONCLUSIONS

This decision analysis strategy yielded a definitive noninvasive diagnosis in 62% of patients with a nondiagnostic scan and appears to be safe.

Authors+Show Affiliations

Medical Clinic 1, Geneva (Switzerland) University Hospital.No affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Clinical Trial
Journal Article
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

8604959

Citation

Perrier, A, et al. "Diagnosis of Pulmonary Embolism By a Decision Analysis-based Strategy Including Clinical Probability, D-dimer Levels, and Ultrasonography: a Management Study." Archives of Internal Medicine, vol. 156, no. 5, 1996, pp. 531-6.
Perrier A, Bounameaux H, Morabia A, et al. 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(5):531-6.
Perrier, A., Bounameaux, H., Morabia, A., de Moerloose, P., Slosman, D., Didier, D., ... Junod, A. (1996). Diagnosis of pulmonary embolism by a decision analysis-based strategy including clinical probability, D-dimer levels, and ultrasonography: a management study. Archives of Internal Medicine, 156(5), pp. 531-6.
Perrier A, et al. 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 Mar 11;156(5):531-6. PubMed PMID: 8604959.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Diagnosis of pulmonary embolism by a decision analysis-based strategy including clinical probability, D-dimer levels, and ultrasonography: a management study. AU - Perrier,A, AU - Bounameaux,H, AU - Morabia,A, AU - de Moerloose,P, AU - Slosman,D, AU - Didier,D, AU - Unger P-F,, AU - Junod,A, PY - 1996/3/11/pubmed PY - 1996/3/11/medline PY - 1996/3/11/entrez SP - 531 EP - 6 JF - Archives of internal medicine JO - Arch. Intern. Med. VL - 156 IS - 5 N2 - BACKGROUND: Assessment of the clinical probability of pulmonary emboli sm, plasma D-dimer measurement, and lower-limb venous compression ultrasonography have all been advocated in the workup of suspected pulmonary embolism, to minimize the requirement for pulmonary angiography in patients with nondiagnostic lung scans. However, their contribution has not been assessed prospectively. METHODS: Three hundred eight consecutive patients who came to the emergency department with suspected pulmonary embolism were managed according to a diagnostic protocol that included clinical probability assessment, lung scan, and sequential noninvasive tests: plasma D-dimer measurement by enzyme-linked immunosorbent assay (a concentration <500 microgram/L ruled out pulmonary embolism) and lower-limb B-mode venous compression ultrasonography (a positive finding was diagnostic of venous thromboembolism). Patients without pulmonary embolism according to the diagnostic workup did not receive anticoagulant treatment. The safety of this approach was assessed by a 6-month follow-up. RESULTS: of the 308 patients, 106 (34%) had a diagnostic lung scan (normal in 43 and high probability in 63). For the remaining 202 patients, noninvasive workup was diagnostic in 125 (62%). Pulmonary embolism was ruled out by a low clinical probability and a nondiagnostic scan in 48 patients and a D-dimer level less than 500 microgram/L in 53; pulmonary embolism was established by a high clinical probability and a nondiagnostic scan in seven patients and by a finding of a deep vein thrombosis on ultrasonography in 17. Therefore, only 77 of these 202 patients underwent pulmonary angiography (negative in 55; positive in 22). At 6-month follow-up (completed for 99.4% of the study population), only two of the 199 patients in whom the diagnostic protocol had ruled out pulmonary embolism (1.0% [95% confidence interval, 0.1 to 3.6]) had a thromboembolic event (pulmonary embolism, one; deep vein thrombosis, one). CONCLUSIONS: This decision analysis strategy yielded a definitive noninvasive diagnosis in 62% of patients with a nondiagnostic scan and appears to be safe. SN - 0003-9926 UR - https://www.unboundmedicine.com/medline/citation/8604959/Diagnosis_of_pulmonary_embolism_by_a_decision_analysis_based_strategy_including_clinical_probability_D_dimer_levels_and_ultrasonography:_a_management_study_ L2 - https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/vol/156/pg/531 DB - PRIME DP - Unbound Medicine ER -