Article

van Belle, A. et al. Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography. JAMA 295, 172-179

Department of Pulmonary Medicine, Academic Hospital, Maastricht, The Netherlands.
JAMA The Journal of the American Medical Association (Impact Factor: 30.39). 02/2006; 295(2):172-9. DOI: 10.1001/jama.295.2.172
Source: PubMed

ABSTRACT Previous studies have evaluated the safety of relatively complex combinations of clinical decision rules and diagnostic tests in patients with suspected pulmonary embolism.
To assess the clinical effectiveness of a simplified algorithm using a dichotomized clinical decision rule, D-dimer testing, and computed tomography (CT) in patients with suspected pulmonary embolism.
Prospective cohort study of consecutive patients with clinically suspected acute pulmonary embolism, conducted in 12 centers in the Netherlands from November 2002 through December 2004. The study population of 3306 patients included 82% outpatients and 57% women.
Patients were categorized as "pulmonary embolism unlikely" or "pulmonary embolism likely" using a dichotomized version of the Wells clinical decision rule. Patients classified as unlikely had D-dimer testing, and pulmonary embolism was considered excluded if the D-dimer test result was normal. All other patients underwent CT, and pulmonary embolism was considered present or excluded based on the results. Anticoagulants were withheld from patients classified as excluded, and all patients were followed up for 3 months.
Symptomatic or fatal venous thromboembolism (VTE) during 3-month follow-up.
Pulmonary embolism was classified as unlikely in 2206 patients (66.7%). The combination of pulmonary embolism unlikely and a normal D-dimer test result occurred in 1057 patients (32.0%), of whom 1028 were not treated with anticoagulants; subsequent nonfatal VTE occurred in 5 patients (0.5% [95% confidence interval {CI}, 0.2%-1.1%]). Computed tomography showed pulmonary embolism in 674 patients (20.4%). Computed tomography excluded pulmonary embolism in 1505 patients, of whom 1436 patients were not treated with anticoagulants; in these patients the 3-month incidence of VTE was 1.3% (95% CI, 0.7%-2.0%). Pulmonary embolism was considered a possible cause of death in 7 patients after a negative CT scan (0.5% [95% CI, 0.2%-1.0%]). The algorithm was completed and allowed a management decision in 97.9% of patients.
A diagnostic management strategy using a simple clinical decision rule, D-dimer testing, and CT is effective in the evaluation and management of patients with clinically suspected pulmonary embolism. Its use is associated with low risk for subsequent fatal and nonfatal VTE.

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    • "D-dimer was defined negative if lower than 500 ng/ml (Fibrinogen Equivalent Unit). This cutoff has been validated for D-dimer use in venous thromboembolic disease and has already been evaluated for the diagnosis of AD in previous studies [18] [19] [22] [23]. "
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    • "The Wells score separates patients into three different categories of low, intermediate and high clinical probability, and can also be used in a dichotomised manner, PE likely versus PE unlikely [19]. It has been widely validated in prospective management outcome studies [20] [21]. The Geneva score in its original version needed arterial blood sample and chest X-ray [22] hence the development and validation of a revised Geneva score including only clinical characteristics [23] [24] [25]. "
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    • "D-dimer was normal in 17.1% of the cases, and combined with a low clinical probability, a hundred percent sensitivity was reached. Van Belle et al. [2] have investigated the use of a clinical decision rule in combination with D-dimer testing in the exclusion of PE. In the clinical decision rule, the variable 'previous pulmonary embolism or deep vein thrombosis' is included. "
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