Best Practices in Acute Pulmonary Embolism Evaluation

Nov 23, 2015   |  Geoffrey D. Barnes, MD, MSc, FACC
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Authors:
Raja AS, Greenberg JO, Qaseem A, Denberg TD, Fitterman N, Schuur JD, on behalf of the Clinical Guidelines Committee of the American College of Physicians.
Citation:
Evaluation of Patients With Suspected Acute Pulmonary Embolism: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med 2015;163:701-711.

The following are key points from this best practice advice on the evaluation of patients with suspected acute pulmonary embolism (PE):

  1. PE can be a severe disease and difficult to diagnose given its nonspecific signs and symptoms.
  2. Overuse of computed tomography (CT) and D-dimer testing may not improve care and may lead to potential hard and unnecessary expense.
  3. Clinicians should use validated clinical prediction rules to estimate pretest probability in patients who may have acute PE. They should use either the Wells Prediction Rule for PE or the Revised Geneva Score for PE.
  4. Clinicians should not obtain D-dimer tests or imaging studies in low pretest probability patients who meet all PE rule-out criteria. Probability of PE is <1% when all criteria are negative. Criteria include age <50 years, initial heart rate <100 bpm, initial oxygen saturation >94% on room air, no unilateral leg swelling, no hemoptysis, no recent surgery or trauma (within 4 weeks), no prior venous thromboembolism, and no estrogen use.
  5. Clinicians should obtain a high-sensitivity D-dimer measurement as the initial diagnostic test in patients with intermediate pretest probability of PE or in patients with low pretest probability who do not meet all of the PE rule-out criteria. Imaging tests should not be the initial test for low or intermediate pretest probability of PE.
  6. Clinicians should use age-adjusted D-dimer thresholds (age x 10 ng/ml) rather than a generic 500 ng/ml threshold to determine if imaging is warranted.
  7. Clinicians should obtain a CT pulmonary angiography (CTPA) in patients with high pretest probability of PE. Ventilation-perfusion scans should be reserved for patients with a contraindication to CTPA or if CTPA is not available. D-dimer testing should not be obtained in patients with high pretest probability of PE.

Keywords: Angiography, Diagnostic Imaging, Diagnostic Tests, Routine, Estrogens, Fibrin Fibrinogen Degradation Products, Hemoptysis, Pulmonary Embolism, Secondary Prevention, Tomography, X-Ray Computed, Vascular Diseases, Venous Thromboembolism


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