Systematic review and meta-analysis of strategies for the diagnosis of suspected pulmonary embolism.
OBJECTIVE
To assess the likelihood ratios of diagnostic strategies for pulmonary embolism and to determine their clinical application according to pretest probability.


METHODS
Medline, Embase, and Pascal Biomed and manual search for articles published from January 1990 to September 2003.


METHODS
Studies that evaluated diagnostic tests for confirmation or exclusion of pulmonary embolism. DATA EXTRACTED: Positive likelihood ratios for strategies that confirmed a diagnosis of pulmonary embolism and negative likelihood ratios for diagnostic strategies that excluded a diagnosis of pulmonary embolism.


RESULTS
48 of 1012 articles were included. Positive likelihood ratios for diagnostic tests were: high probability ventilation perfusion lung scan 18.3 (95% confidence interval 10.3 to 32.5), spiral computed tomography 24.1 (12.4 to 46.7), and ultrasonography of leg veins 16.2 (5.6 to 46.7). In patients with a moderate or high pretest probability, these findings are associated with a greater than 85% post-test probability of pulmonary embolism. Negative likelihood ratios were: normal or near normal appearance on lung scan 0.05 (0.03 to 0.10), a negative result on spiral computed tomography along with a negative result on ultrasonography 0.04 (0.03 to 0.06), and a d-dimer concentration < 500 mug/l measured by quantitative enzyme linked immunosorbent assay 0.08 (0.04 to 0.18). In patients with a low or moderate pretest probability, these findings were associated with a post-test probability of pulmonary embolism below 5%. Spiral computed tomography alone, a low probability ventilation perfusion lung scan, magnetic resonance angiography, a quantitative latex d-dimer test, and haemagglutination d-dimers had higher negative likelihood ratios and can therefore only exclude pulmonary embolism in patients with a low pretest probability.


CONCLUSIONS
The accuracy of tests for suspected pulmonary embolism varies greatly, but it is possible to estimate the range of pretest probabilities over which each test or strategy can confirm or rule out pulmonary embolism.
Roy
Pierre-Marie
PM
Emergency Department, Centre Hospitalier Universitaire, 49033 Angers cedex 01, France.
Colombet
Isabelle
I
Durieux
Pierre
P
Chatellier
Gilles
G
Sors
Hervé
H
Meyer
Guy
G
D004452:Echocardiography / Q000592:standards; D005338:Fibrin Fibrinogen Degradation Products / Q000032:analysis; D006801:Humans; D007866:Leg / Q000098:blood supply; D016013:Likelihood Functions; D018810:Magnetic Resonance Angiography / Q000592:standards; D011655:Pulmonary Embolism / Q000175:diagnosis* / Q000000981:diagnostic imaging; D011877:Radionuclide Imaging; D012680:Sensitivity and Specificity; D036542:Tomography, Spiral Computed / Q000592:standards; D014680:Veins / Q000502:physiology
D005338:Fibrin Fibrinogen Degradation Products; C036309:fibrin fragment D