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A Combined Approach to Ruling Out Pulmonary Embolism

No patient with a low clinical probability of PE and a negative D-dimer test developed PE during 3 months of follow-up.

Neither clinical assessment nor use of D-dimer testing alone is sufficiently accurate in ruling out pulmonary embolism (PE) to comfortably withhold treatment from patients. Dutch investigators combined these 2 approaches in a prospective assessment of 234 consecutive patients with suspected PE; the clinical risk assessment included signs and symptoms of PE, chest x-ray, oxygen saturation testing, electrocardiogram, and the likelihood of alternative diagnoses.

Sixty (26%) patients with low clinical probabilities of PE and negative D-dimer tests received no further evaluation or anticoagulation. During 3 months of follow-up, 57 of these patients had no evidence of PE; 3 underwent pulmonary angiography for continued PE concerns, but all angiograms were negative. Of the remaining 174 patients at higher clinical risk or with positive D-dimer tests, 52 had PE detected by subsequent pulmonary angiography: 27 had deep-vein thrombosis (DVT) detected by compression ultrasonography, and 25 had no evidence of DVT. In a subgroup of 85 patients with low or moderate clinical risk for PE and negative D-dimer tests, only 1 patient had a positive pulmonary angiogram.

Comment: These results suggest that expensive testing can be avoided safely in approximately one quarter of patients who present with possible PE but have low-probability clinical assessments and negative D-dimer tests; the negative predictive value was 100% in these patients. Whether this seemingly sensible approach can be implemented in the litigious U.S. environment is unclear.

— Thomas L. Schwenk, MD

Published in Journal Watch General Medicine August 9, 2002

Citation(s):

Kruip MJHA et al. Use of a clinical decision rule in combination with D-dimer concentration in diagnostic workup of patients with suspected pulmonary embolism: A prospective management study. Arch Intern Med 2002 Jul 22; 162:1631-5.

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