Non-invasive diagnosis of pulmonary embolism, anno 2005.
Pulmonary angiography is the gold standard for segmental pulmonary embolism (PE) but no longer for subsegmental PE, because the inter-observer agreement for angiographically documented subsegmental PE is only 60%. Two non-invasive tools exclude PE with a negative predictive value of >99% : a normal perfusion lung scan and a normal rapid ELISA VIDAS D-dimer test. The positive predictive value is 85 to 88% for a high probability ventilation-perfusion lung scan (VP-scan) and >95% for helical spiral CT. The prevalence of PE in management studies of symptomatic patients with a non-diagnostic VP-scan is 20 to 24%. Helical spiral CT detects all clinically relevant PE and a large number of alternative diagnoses in symptomatic patients with a non-diagnostic VP-scan or a high probability VP-scan. Single-slice helical CT as the primary diagnostic test in patients with suspected PE in three retrospective studies and in two prospective management study indicate that the negative predictive value of a normal helical spiral CT, a negative compression ultrasonography of the legs (CUS) together with a low or intermediate pre-test clinical probability is >99%. Therefore, helical spiral CT can replace both the VP-scan and pulmonary angiography to safely rule in and out PE. The combination of clinical assessment, a rapid ELISA VIDAS D-dimer followed by CUS will reduce the need for helical spiral CT by 40 to 50%.
Michiels
J J
JJ
Goodheart Institute and Foundation, Hemostasis Thrombosis and Vascular Research, Goodheart Institute, Rotterdam, The Netherlands. postbus@goodheartcenter.demon.nl
Hoogsteden
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H
Pattynama
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PM
D000792:Angiography; D004797:Enzyme-Linked Immunosorbent Assay; D005338:Fibrin Fibrinogen Degradation Products / Q000032:analysis; D006801:Humans; D011655:Pulmonary Embolism / Q000097:blood / Q000175:diagnosis*; D036542:Tomography, Spiral Computed
D005338:Fibrin Fibrinogen Degradation Products; C036309:fibrin fragment D