Diagnostic management of pulmonary embolism using clinical assessment, plasma D-dimer assay, complete lower limb venous ultrasound and helical computed tomography of pulmonary arteries. A multicentre clinical outcome study.
The objective of the study was to assess the clinical validity of a non-invasive diagnostic strategy for acute pulmonary embolism using clinical assessment combined with both ELISA D-dimer and complete lower limb ultrasound (US) examination of proximal and distal veins, before single-detector helical computed tomography (CT) of pulmonary arteries. We expected the strategy to have a high diagnostic exclusion power and to safely decrease the number of CT scans. This prospective, multicenter outcome study included 274 consecutive outpatients. All underwent a priori clinical probability, D-dimer and bilateral complete lower limb US assessments. Only patients with a high clinical probability and both tests negative, or positive D-dimer and negative US assessments, underwent CT. This was deemed necessary in 114 patients (42%). At baseline, venous thromboembolism (VTE) was detected in 110 patients (40%), either by US showing proximal (n=65) or distal (n=36) thrombosis, or by CT (n=9). Anticoagulant was withheld in the remaining patients with negative results in both D-dimer and US but a non-high clinical probability (n=59), or in both US and CT (n=90), or with negative US (n=6) and inadequate CT (n=9). All patients underwent a three-month clinical follow-up. VTE occurred in one patient with inadequate CT, yielding an incidence of 0.6% [95% confidence interval: 0.1-3.4]. No patient died from VTE or had major bleeding. Using clinical probability, ELISA D-dimer and complete US before helical CT is a safe strategy resulting in a substantial reduction in CT scans.
Elias
Antoine
A
Department of Vascular Medicine, Rangueil University Hospital Centre, Toulouse, France. elias.a@chu-toulouse.fr
Cazanave
Alain
A
Elias
Marie
M
Chabbert
Valérie
V
Juchet
Henri
H
Paradis
Hélène
H
Carrière
Philippe
P
Nguyen
Françoise
F
Didier
Alain
A
Galinier
Michel
M
Colin
Cyrille
C
Lauque
Dominique
D
Joffre
Francis
F
Rousseau
Hervé
H
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000627:therapeutic use; D004797:Enzyme-Linked Immunosorbent Assay; D005260:Female; D005338:Fibrin Fibrinogen Degradation Products / Q000096:biosynthesis*; D005500:Follow-Up Studies; D006801:Humans; D035002:Lower Extremity / Q000098:blood supply; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D011651:Pulmonary Artery / Q000473:pathology*; D011655:Pulmonary Embolism / Q000097:blood* / Q000175:diagnosis*; D015203:Reproducibility of Results; D013923:Thromboembolism / Q000175:diagnosis; D013927:Thrombosis / Q000175:diagnosis; D013997:Time Factors; D036542:Tomography, Spiral Computed / Q000379:methods*; D016896:Treatment Outcome; D014463:Ultrasonography; D014680:Veins / Q000000981:diagnostic imaging*; D020246:Venous Thrombosis / Q000175:diagnosis
D000925:Anticoagulants; D005338:Fibrin Fibrinogen Degradation Products; C036309:fibrin fragment D