Article

Validation of helical computed tomography for suspected pulmonary embolism: a near miss?

Division of General Internal Medicine, Department of Internal Medicine, Geneva Faculty of Medicine and Geneva University Hospital, Geneva, Switerland.
Journal of Thrombosis and Haemostasis (Impact Factor: 5.72). 02/2005; 3(1):14-6. DOI: 10.1111/j.1538-7836.2004.01073.x
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Available from: Henri Bounameaux, Oct 07, 2014
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    ABSTRACT: A prospective outcome study designed to evaluate a simple strategy for the management of outpatients with suspected pulmonary embolism (PE), based on clinical probability, D-dimer, and multi-slice computed tomography (MSCT). A cohort of 432 consecutive patients admitted to the emergency department with suspected PE was managed by sequential non-invasive testing. Patients in whom PE was ruled out were not given anticoagulants, but were followed-up for 3 months. Normal D-dimer and low-intermediate clinical probability ruled out PE in 103 patients [24% (95% CI 20-28)]. Seventeen patients had normal D-dimer, but high clinical probability and proceeded to MSCT. All patients proved negative for PE. A total of 329 (76%) patients underwent MSCT examination. Pulmonary embolism was diagnosed in 93 patients [21.5% (95% CI 18-26)] and was ruled out by negative MSCT in 221 patients [51% (95% CI 46-56)]. MSCT scans were determined as inconclusive in 15 (4.5%) patients. No patient developed objectively verified venous thromboembolism (VTE) during the 3-month follow-up period. However, the cause of death was adjudicated as possibly related to PE in two patients, resulting in an overall 3-month VTE risk of 0.6% (95% CI 0-2.2%). The diagnostic algorithm yielded a definite diagnosis in 96.5% of the patients. This simple and non-invasive strategy combining clinical probability, D-dimer, and MSCT for the management of outpatients with suspected PE appears to be safe and effective.
    Full-text · Article · Oct 2005 · Journal of Thrombosis and Haemostasis
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    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.
    Full-text · Article · Feb 2006 · JAMA The Journal of the American Medical Association
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    ABSTRACT: La maladie thromboembolique veineuse est de plus en plus reconnue comme une cause importante de morbidité et de mortalité en pédiatrie. Elle survient en général dans le contexte d’une pathologie sévère de l’enfant, en particulier en tant que complication des néoplasies, des maladies auto-immunes et est souvent localisée à l’endroit des abords vasculaires (port-a-cath, voies veineuses centrales etc.) L’approche diagnostique et thérapeutique de la maladie thromboembolique veineuse a été largement étudiée et validée chez l’adulte, alors même qu’il n’existe qu’un nombre très restreint d’études prospectives dans le domaine pédiatrique. Le diagnostic de la maladie thromboembolique veineuse chez l’enfant repose donc essentiellement sur l’utilisation de tests et de stratégies qui ont été extrapolés des données obtenues à partir d’études ayant inclus uniquement des adultes mais qui n’ont jamais été correctement évaluées chez l’enfant. Au-delà de ce premier écueil purement diagnostique, la prise en charge thérapeutique souffre également d’un manque important de données solides. En effet, peu d’études ont validé de manière adéquate l’utilisation des anticoagulants chez l’enfant. Les médicaments utilisés, les doses et les intervalles thérapeutiques visés sont donc basés sur des extrapolations venant des données rapportées par les études chez l’adulte. Pourtant, la notion de « developemental haemostasis », c’est-à-dire d’un système hémostatique très différent et en évolution dynamique au cours de toute la période de l’enfance, est largement admise et suggère clairement que les attitudes thérapeutiques chez l’enfant ne devraient pas simplement être extrapolées des données adultes.
    No preview · Article · Jul 2006 · Journal des Maladies Vasculaires
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