Challenges in the Diagnosis Acute Pulmonary Embolism - 20/08/11

Doi : 10.1016/j.amjmed.2008.02.033

Paul D. Stein, MD ^a,^b,^⁎ , H. Dirk Sostman, MD ^c, Henri Bounameaux, MD ^d, Harry R. Buller, MD ^e, Thomas L. Chenevert, PhD ^f, James E. Dalen, MD ^g, Lawrence R. Goodman, MD ^h, Alexander Gottschalk, MD ⁱ, Russell D. Hull, MBBS, MSc ^j, Kenneth V. Leeper, MD ^k, Massimo Pistolesi, MD ^l, Gary E. Raskob, PhD ^m, Philip S. Wells, MD ⁿ, Pamela K. Woodard, MD ^o
^a Department of Research, St Joseph Mercy Oakland Hospital, Pontiac, Mich
^b Department of Medicine, Wayne State University, Detroit, Mich
^c Office of the Dean, Weill Cornell Medical College and Methodist Hospital, Houston, Tex
^d Department of Medicine, University of Geneva, Geneva, Switzerland
^e Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands
^f Department of Radiology, University of Michigan, Ann Arbor
^g College of Medicine and College of Public Health, University of Arizona, Tucson
^h Department of Radiology, Medical College of Wisconsin, Milwaukee
ⁱ Department of Radiology, Michigan State University, East Lansing
^j Department of Medicine, University of Calgary, Calgary, Alberta, Canada
^k Department of Medicine, Emory University, Atlanta, Ga
^l Department of Critical Care, University of Florence, Florence, Italy
^m Department of Epidemiology and Medicine, University of Oklahoma Health Sciences Center, Oklahoma City
ⁿ Department of Medicine, University of Ottawa and Ottawa Health Research Institute, Ottawa, Canada
^o Department of Radiology, Washington University, St Louis, Mo.

Requests for reprints should be addressed to Paul D. Stein, MD, Saint Joseph Mercy Oakland, 44405 Woodward Avenue. Pontiac, MI 48341-5023.

Abstract

The state of the art of diagnostic evaluation of hemodynamically stable patients with suspected acute pulmonary embolism was reviewed. Diagnostic evaluation should begin with clinical assessment using a validated prediction rule in combination with measurement of D-dimer when appropriate. Imaging should follow only when necessary. Although with 4-slice computed tomography (CT) and 16-slice CT, the sensitivity for detection of pulmonary embolism was increased by combining CT angiography with CT venography, it is not known whether CT venography increases the sensitivity of 64-slice CT angiography. Methods to reduce the radiation exposure of CT venography include imaging only the proximal leg veins (excluding the pelvis) and obtaining discontinuous images. Compression ultrasound can be used instead. In young women, radiation of the breasts produces the greatest risk of radiation-induced cancer. It may be that scintigraphy is the imaging test of choice in such patients, but this pathway should be tested prospectively. A patient-specific approach to the diagnosis of pulmonary embolism can be taken safely in hemodynamically stable patients to increase efficiency and decrease cost and exposure to radiation.

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Keywords : Computed tomography angiography, D-dimer, Pulmonary embolism, Thromboembolism, Ventilation-perfusion scintigraphy