title: The rehabilitation of clinical assessment for the diagnosis of pulmonary embolism.
abstract: Pulmonary angiography is the gold standard for diagnosis of segmental pulmonary embolism, but no longer for subsegmental pulmonary embolism because the inter-observer agreement for angiographically documented subsegmental pulmonary embolism is only 60%. A normal rapid ELISA VIDAS D-dimer test result and a normal perfusion scan exclude pulmonary embolism with a negative predictive value of >99%, irrespective of clinical score. The positive predictive value for pulmonary embolism of a high probability VP-scan compared to pulmonary angiography is 87% indicating that 13% of patients with a high probability VP-scan do not have pulmonary embolism. The combination of a negative CUS, a low clinical score, and a non-diagnostic VP-scan safely excludes pulmonary embolism. Patients with a non-diagnostic VP-scan, a negative CUS, but a moderate to high clinical score are candidates for pulmonary angiography. The positive predictive value of helical spiral CT is >95 to 99%. The combination of a negative CUS, a low clinical score, and the presence of a clear alternative diagnosis is predicted to safely exclude pulmonary embolism. Helical spiral CT detects all clinical relevant pulmonary emboli and a large number of alternative diagnoses in symptomatic patients with a non-diagnostic or a high-probability VP-scan. The negative predictive value during 3 months followup after a negative spiral CT for pulmonary embolism in 4 retrospective studies and 1 prospective management study was >99%. Only a small group of patients (1-2%) with a non-diagnostic spiral CT are candidates for pulmonary angiography. Therefore, it is predicted that the spiral CT will replace both VP-scanning and pulmonary angiography to safely exclude or diagnose pulmonary emboli in patients with suspected pulmonary embolism.
authors.forename: Jan Jacques
authors.initials: JJ
authors.lastname: Michiels
authors.forename: Ari
authors.initials: A
authors.lastname: Berghout
authors.forename: Wilfried
authors.initials: W
authors.lastname: Schroyens
authors.forename: Wilfried
authors.initials: W
authors.lastname: De Backer
authors.forename: Henk
authors.initials: H
authors.lastname: Hoogsteden
authors.forename: Peter M T
authors.initials: PM
authors.lastname: Pattynama
mesh_terms: D000792:Angiography; D005338:Fibrin Fibrinogen Degradation Products / Q000032:analysis; D006801:Humans; D011655:Pulmonary Embolism / Q000097:blood / Q000175:diagnosis*; D011877:Radionuclide Imaging; D036542:Tomography, Spiral Computed; D014463:Ultrasonography
chemical_list: D005338:Fibrin Fibrinogen Degradation Products; C036309:fibrin fragment D