Performance of a diagnostic algorithm based on a prediction rule, D-dimer and CT-scan for pulmonary embolism in patients with previous venous thromboembolism. A systematic review and meta-analysis.
Diagnostic management of suspected pulmonary embolism (PE) in patients with a history of venous thromboembolism (VTE) is complicated due to persistent abnormal D-dimer levels, residual embolic obstruction and higher clinical prediction rule (CPR) scores. We aimed to evaluate the safety and efficiency of the standard diagnostic algorithm consisting of a CPR, D-dimer test and computed tomography pulmonary angiography (CTPA) in this specific patient category. We performed a systematic literature search for prospective studies evaluating a diagnostic algorithm in consecutive patients with clinically suspected PE and a history of VTE. The VTE incidence rates during three-month follow-up and the number of indicated CTPAs were pooled using random effect models. Four studies concerning 1,286 patients were included with a pooled baseline PE prevalence of 36 % (95 % confidence interval [CI] 30-42). In only 217 patients (15 %; 95 %CI 11-20) PE could be excluded without CTPA. The three-month VTE incidence rate was 0.8 % (95 %CI 0.06-2.4) in patients managed without CTPA, 1.6 % (95 %CI 0.3-4.0) in patients in whom PE was excluded by CTPA and 1.4 % (95 %CI 0.6-2.7) overall. In the pooled studies, PE was safely excluded in patients with a history of VTE based on a CPR followed by a D-dimer test and/or CTPA, although the efficiency of the algorithm is relatively low compared to patients without a history of VTE.
Maria José
MJ
Fabiá Valls
Tom van der Hulle, MD, Department of Thrombosis and Hemostasis, Leiden University Medical Center, Albinusdreef 2, P. O. Box 9600, 2300 RC, Leiden, The Netherlands, Tel: +31 71 526 8132, Fax: +31 71 526 6868, E-mail: t.van_der_hulle@lumc.nl.
Tom
T
van der Hulle
Paul L
PL
den Exter
Inge C M
IC
Mos
Menno V
MV
Huisman
Frederikus A
FA
Klok
D000465:Algorithms; D000792:Angiography; D002309:Cardiology / Q000592:standards; D003661:Decision Support Techniques; D005338:Fibrin Fibrinogen Degradation Products / Q000737:chemistry*; D006801:Humans; D015994:Incidence; D015995:Prevalence; D011446:Prospective Studies; D011655:Pulmonary Embolism / Q000097:blood / Q000175:diagnosis* / Q000000981:diagnostic imaging; D014057:Tomography, X-Ray Computed; D054556:Venous Thromboembolism / Q000150:complications / Q000175:diagnosis*
D005338:Fibrin Fibrinogen Degradation Products; C036309:fibrin fragment D
D-dimer; Pulmonary embolism; diagnosis; meta-analysis; multidetector computed tomography; safety