Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography.
BACKGROUND
Previous studies have evaluated the safety of relatively complex combinations of clinical decision rules and diagnostic tests in patients with suspected pulmonary embolism.


OBJECTIVE
To assess the clinical effectiveness of a simplified algorithm using a dichotomized clinical decision rule, D-dimer testing, and computed tomography (CT) in patients with suspected pulmonary embolism.


METHODS
Prospective cohort study of consecutive patients with clinically suspected acute pulmonary embolism, conducted in 12 centers in the Netherlands from November 2002 through December 2004. The study population of 3306 patients included 82% outpatients and 57% women.


METHODS
Patients were categorized as "pulmonary embolism unlikely" or "pulmonary embolism likely" using a dichotomized version of the Wells clinical decision rule. Patients classified as unlikely had D-dimer testing, and pulmonary embolism was considered excluded if the D-dimer test result was normal. All other patients underwent CT, and pulmonary embolism was considered present or excluded based on the results. Anticoagulants were withheld from patients classified as excluded, and all patients were followed up for 3 months.


METHODS
Symptomatic or fatal venous thromboembolism (VTE) during 3-month follow-up.


RESULTS
Pulmonary embolism was classified as unlikely in 2206 patients (66.7%). The combination of pulmonary embolism unlikely and a normal D-dimer test result occurred in 1057 patients (32.0%), of whom 1028 were not treated with anticoagulants; subsequent nonfatal VTE occurred in 5 patients (0.5% [95% confidence interval {CI}, 0.2%-1.1%]). Computed tomography showed pulmonary embolism in 674 patients (20.4%). Computed tomography excluded pulmonary embolism in 1505 patients, of whom 1436 patients were not treated with anticoagulants; in these patients the 3-month incidence of VTE was 1.3% (95% CI, 0.7%-2.0%). Pulmonary embolism was considered a possible cause of death in 7 patients after a negative CT scan (0.5% [95% CI, 0.2%-1.0%]). The algorithm was completed and allowed a management decision in 97.9% of patients.


CONCLUSIONS
A diagnostic management strategy using a simple clinical decision rule, D-dimer testing, and CT is effective in the evaluation and management of patients with clinically suspected pulmonary embolism. Its use is associated with low risk for subsequent fatal and nonfatal VTE.
van Belle
Arne
A
Department of Pulmonary Medicine, Academic Hospital, Maastricht, The Netherlands.
Büller
Harry R
HR
Huisman
Menno V
MV
Huisman
Peter M
PM
Kaasjager
Karin
K
Kamphuisen
Pieter W
PW
Kramer
Mark H H
MH
Kruip
Marieke J H A
MJ
Kwakkel-van Erp
Johanna M
JM
Leebeek
Frank W G
FW
Nijkeuter
Mathilde
M
Prins
Martin H
MH
Sohne
Maaike
M
Tick
Lidwine W
LW
D000328:Adult; D000368:Aged; D000465:Algorithms; D000925:Anticoagulants / Q000627:therapeutic use; D003662:Decision Theory; D005260:Female; D005338:Fibrin Fibrinogen Degradation Products / Q000032:analysis; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D011655:Pulmonary Embolism / Q000097:blood / Q000150:complications / Q000175:diagnosis* / Q000188:drug therapy*; D013923:Thromboembolism / Q000150:complications / Q000517:prevention & control; D014057:Tomography, X-Ray Computed
D000925:Anticoagulants; D005338:Fibrin Fibrinogen Degradation Products; C036309:fibrin fragment D