Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II investigators.
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.
Stein
Paul D
PD
Department of Research, St. Joseph Mercy Oakland Hospital, Pontiac, Mich 48341-5023, USA. steinp@trinity-health.org
Woodard
Pamela K
PK
Weg
John G
JG
Wakefield
Thomas W
TW
Tapson
Victor F
VF
Sostman
H Dirk
HD
Sos
Thomas A
TA
Quinn
Deborah A
DA
Leeper
Kenneth V
KV
Hull
Russell D
RD
Hales
Charles A
CA
Gottschalk
Alexander
A
Goodman
Lawrence R
LR
Fowler
Sarah E
SE
Buckley
John D
JD
D000208:Acute Disease; D003663:Decision Trees; D011655:Pulmonary Embolism / Q000175:diagnosis*