[The diagnosis of pulmonary embolism: the best strategies according to the results of a large Dutch multicentre study].
The Dutch national guidelines for the diagnosis of patients with clinically suspected pulmonary embolism (from 1992 en 1998) are poorly followed in clinical practice, due especially to practical objections. A large multicentre trial to investigate the diagnostic accuracy of the available modalities and of recently developed techniques such as D-dimer determination, (99m)Tc-gas-scintigraphy and spiral CT scanning was started in I997. In the first phase, the diagnostic value was assessed of: spiral CT (sensitivity 69%, specificity 84%; sensitivity for segmental and larger pulmonary embolisms (PE) 86% and for subsegmental PE 21%), (99m)Tc-gas-ventilation scintigraphy (no improvement compared to conventional ventilation scintigraphy), D-dimer determination (sensitivity for segmental PE 93% and for subsegmental PE 53%, specificity 63%), clinical decision rules (in combination with D-dimer determination; sensitivity 100%, specificity 11%) and echography of the deep venous system (sensitivity 26% for segmental PE and 7% for subsegmental PE, specificity 97%). In the second phase, the feasibility of two new potentially cost-effective diagnostic algorithms was evaluated on the basis of the results obtained in the first phase and data in the literature. In 631 patients, a clinical risk estimate was made and D-dimer determination was done, followed by a ventilation-perfusion scan and serial compression echography of the leg veins. An apparent recurrence of PE occurred in 6 of 466 patients in whom no PE had been found originally (1.3%; 95% CI: 0.5-2.8). The average costs were 812 Euro,--per patient. In 510 patients, a spiral CT followed by compression echography was performed. Recurrent PE occurred in 3 of 378 patients with initial normal tests (0.8%; 95% CI: 0.2-2.3). The average costs were 883 Euro,--per patient. A combination of both strategies can be cost-effective with a cost 674 Euro,--per patient (recurrence rate: 1.9%). Both the strategy starting with a clinical-risk estimate and a D-dimer determination as well as the strategy consisting of spiral CT and serial echography were safe and cost-effective. According to the results of a survey of hospital directors, internists and pulmonologists, both are well accepted in clinical practice.
van Strijen
M J L
MJ
Leids Universitair Medisch Centrum, Leiden. m.van.strijen@antonius.net
ten
Wolde M
WM
Pattynama
P M T
PM
Postmus
P E
PE
Büller
H R
HR
Kieft
G J
GJ
Banga
J D
JD
Huisman
M V
MV
D000465:Algorithms; D003287:Contrast Media; D003362:Cost-Benefit Analysis; D006801:Humans; D015337:Multicenter Studies as Topic; D011237:Predictive Value of Tests; D011655:Pulmonary Embolism / Q000175:diagnosis* / Q000000981:diagnostic imaging; D011877:Radionuclide Imaging / Q000191:economics / Q000379:methods*; D019275:Radiopharmaceuticals; D012680:Sensitivity and Specificity; D036542:Tomography, Spiral Computed / Q000191:economics / Q000379:methods*
D003287:Contrast Media; D019275:Radiopharmaceuticals