title: Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II investigators.
abstract: OBJECTIVE
  To formulate comprehensive recommendations for the diagnostic approach to patients with suspected pulmonary embolism, based on randomized trials.
  
  
  METHODS
  Diagnostic management recommendations were formulated based on results of the Prospective Investigation of Pulmonary Embolism Diagnosis II (PIOPED II) and outcome studies.
  
  
  RESULTS
  The PIOPED II investigators recommend stratification of all patients with suspected pulmonary embolism according to an objective clinical probability assessment. D-dimer should be measured by the quantitative rapid enzyme-linked immunosorbent assay (ELISA), and the combination of a negative D-dimer with a low or moderate clinical probability can safely exclude pulmonary embolism in many patients. If pulmonary embolism is not excluded, contrast-enhanced computed tomographic pulmonary angiography (CT angiography) in combination with venous phase imaging (CT venography), is recommended by most PIOPED II investigators, although CT angiography plus clinical assessment is an option. In pregnant women, ventilation/perfusion scans are recommended by many as the first imaging test following D-dimer and perhaps venous ultrasound. In patients with discordant findings of clinical assessment and CT angiograms or CT angiogram/CT venogram, further evaluation may be necessary.
  
  
  CONCLUSIONS
  The sequence for diagnostic test in patients with suspected pulmonary embolism depends on the clinical circumstances.
authors.affiliation: Department of Research, St. Joseph Mercy Oakland Hospital, Pontiac, Mich 48341-5023, USA. steinp@trinity-health.org
authors.forename: Paul D
authors.initials: PD
authors.lastname: Stein
authors.forename: Pamela K
authors.initials: PK
authors.lastname: Woodard
authors.forename: John G
authors.initials: JG
authors.lastname: Weg
authors.forename: Thomas W
authors.initials: TW
authors.lastname: Wakefield
authors.forename: Victor F
authors.initials: VF
authors.lastname: Tapson
authors.forename: H Dirk
authors.initials: HD
authors.lastname: Sostman
authors.forename: Thomas A
authors.initials: TA
authors.lastname: Sos
authors.forename: Deborah A
authors.initials: DA
authors.lastname: Quinn
authors.forename: Kenneth V
authors.initials: KV
authors.lastname: Leeper
authors.forename: Russell D
authors.initials: RD
authors.lastname: Hull
authors.forename: Charles A
authors.initials: CA
authors.lastname: Hales
authors.forename: Alexander
authors.initials: A
authors.lastname: Gottschalk
authors.forename: Lawrence R
authors.initials: LR
authors.lastname: Goodman
authors.forename: Sarah E
authors.initials: SE
authors.lastname: Fowler
authors.forename: John D
authors.initials: JD
authors.lastname: Buckley
mesh_terms: D000208:Acute Disease; D003663:Decision Trees; D011655:Pulmonary Embolism / Q000175:diagnosis*