title: Diagnostic outcome management study in patients with clinically suspected recurrent acute pulmonary embolism with a structured algorithm.
abstract: BACKGROUND
  The value of diagnostic strategies in patients with clinically suspected recurrent pulmonary embolism (PE) has not been established. The aim was to determine the safety of a simple diagnostic strategy using the Wells clinical decision rule (CDR), quantitative D-dimer testing and computed tomography pulmonary angiography (CTPA) in patients with clinically suspected acute recurrent PE.
  
  
  METHODS
  Multicenter clinical outcome study in 516 consecutive patients with clinically suspected acute recurrent PE without using anticoagulants.
  
  
  RESULTS
  An unlikely clinical probability (Wells rule 4 points or less) was found in 182 of 516 patients (35%), and the combination of an unlikely CDR-score and normal D-dimer result excluded PE in 88 of 516 patients (17%), without recurrent venous thromboembolism (VTE) during 3month follow-up (0%; 95% CI 0.0-3.4%). CTPA was performed in all other patients and confirmed recurrent PE in 172 patients (overall prevalence of PE 33%) and excluded PE in the remaining 253 patients (49%). During follow-up, seven of these 253 patients returned with recurrent VTE (2.8%; 95% CI 1.2-5.5%), of which in one was fatal (0.4 %; 95 % CI 0.02-1.9%). The diagnostic algorithm was feasible in 98% of patients.
  
  
  CONCLUSIONS
  A diagnostic algorithm consisting of a clinical decision rule, D-dimer test and CTPA is effective in the management of patients with clinically suspected acute recurrent PE. CTPA provides reasonable safety in excluding acute recurrent PE in patients with a likely clinical probability or an elevated D-dimer test for recurrent PE, with a low risk for fatal PE at follow-up.
authors.affiliation: Department of Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, The Netherlands. Electronic address: i.c.m.mos@lumc.nl.
authors.forename: Inge C M
authors.initials: IC
authors.lastname: Mos
authors.affiliation: Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands.
authors.forename: Renée A
authors.initials: RA
authors.lastname: Douma
authors.affiliation: School for Public Health and Primary Care, Maastricht University Medical Center, Maastricht, The Netherlands; Lab Clinical Thrombosis and Haemostasis, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands.
authors.forename: Petra M G
authors.initials: PM
authors.lastname: Erkens
authors.affiliation: Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands.
authors.forename: Marieke J H A
authors.initials: MJ
authors.lastname: Kruip
authors.affiliation: Department of Internal Medicine, Rijnstate Hospital Arnhem, Arnhem, The Netherlands.
authors.forename: Marcel M
authors.initials: MM
authors.lastname: Hovens
authors.affiliation: Department of Internal Medicine, Maasstad Hospital, Rotterdam, The Netherlands.
authors.forename: Anja A
authors.initials: AA
authors.lastname: van Houten
authors.affiliation: Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands.
authors.forename: Herman M A
authors.initials: HM
authors.lastname: Hofstee
authors.affiliation: Department of Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: Judith
authors.initials: J
authors.lastname: Kooiman
authors.affiliation: Department of Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: Frederikus A
authors.initials: FA
authors.lastname: Klok
authors.affiliation: Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands.
authors.forename: Harry R
authors.initials: HR
authors.lastname: Büller
authors.affiliation: Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands; Department of Vascular Medicine, University Medical Center, Groningen, The Netherlands.
authors.forename: Pieter W
authors.initials: PW
authors.lastname: Kamphuisen
authors.affiliation: Department of Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: Menno V
authors.initials: MV
authors.lastname: Huisman
mesh_terms: D000208:Acute Disease; D000465:Algorithms; D000792:Angiography / Q000379:methods; D005260:Female; D005338:Fibrin Fibrinogen Degradation Products / Q000032:analysis; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D011655:Pulmonary Embolism / Q000097:blood / Q000175:diagnosis*; D014057:Tomography, X-Ray Computed / Q000379:methods; D016896:Treatment Outcome
chemical_list: D005338:Fibrin Fibrinogen Degradation Products; C036309:fibrin fragment D
keywords: Computed tomography; Diagnosis; Pulmonary embolism; Venous thromboebolism