The American Journal of Medicine
Volume 119, Issue 12 , Pages 1048-1055, December 2006

Diagnostic Pathways in Acute Pulmonary Embolism: Recommendations of The PIOPED II Investigators

  • Paul D. Stein, MD

      Affiliations

    • Department of Research, St. Joseph Mercy Oakland Hospital, Pontiac, Mich
    • Department of Medicine, Wayne State University, Detroit, Mich
    • Corresponding Author InformationRequests for reprints should be addressed to Paul Stein, MD, St. Joseph Mercy Oakland Hospital, 44405 Woodward Ave., Pontiac, MI 48341-5023.
    • ,
  • Pamela K. Woodard, MD

      Affiliations

    • Department of Radiology, Washington University, St. Louis, Mo
    • ,
  • John G. Weg, MD

      Affiliations

    • Department of Medicine, University of Michigan, Ann Arbor
    • ,
  • Thomas W. Wakefield, MD

      Affiliations

    • Department of Surgery, University of Michigan, Ann Arbor
    • ,
  • Victor F. Tapson, MD

      Affiliations

    • Department of Medicine, Duke University, Durham, NC
    • ,
  • H. Dirk Sostman, MD

      Affiliations

    • Office of the Dean, Weill Cornell Medical College, New York, NY
    • Office of the Executive Vice President, Methodist Hospital, Houston, Tex
    • ,
  • Thomas A. Sos, MD

      Affiliations

    • Department of Radiology, Weill Cornell Medical College, New York, NY
    • ,
  • Deborah A. Quinn, MD

      Affiliations

    • Department of Medicine, Massachusetts General Hospital, Boston
    • Harvard Medical School, Boston, Mass
    • ,
  • Kenneth V. Leeper Jr, MD

      Affiliations

    • Department of Medicine, Emory University, Atlanta, Ga
    • ,
  • Russell D. Hull, MBBS, MSc

      Affiliations

    • Department of Medicine, University of Calgary, Calgary, Alberta, Canada
    • ,
  • Charles A. Hales, MD

      Affiliations

    • Department of Medicine, Massachusetts General Hospital, Boston
    • Harvard Medical School, Boston, Mass
    • ,
  • Alexander Gottschalk, MD

      Affiliations

    • Department of Radiology, Michigan State University, East Lansing
    • ,
  • Lawrence R. Goodman, MD

      Affiliations

    • Department of Radiology, Medical College of Wisconsin, Milwaukee
    • ,
  • Sarah E. Fowler, PhD

      Affiliations

    • The Biostatistics Center, Department of Epidemiology and Biostatistics, George Washington University, Rockville, Md
    • ,
  • John D. Buckley, MD, MPH

      Affiliations

    • Department of Medicine, Henry Ford Hospital, Detroit, Mich.

Abstract 

Purpose

To formulate comprehensive recommendations for the diagnostic approach to patients with suspected pulmonary embolism, based on randomized trials.

Methods

Diagnostic management recommendations were formulated based on results of the Prospective Investigation of Pulmonary Embolism Diagnosis II (PIOPED II) and outcome studies.

Results

The PIOPED II investigators recommend stratification of all patients with suspected pulmonary embolism according to an objective clinical probability assessment. D-dimer should be measured by the quantitative rapid enzyme-linked immunosorbent assay (ELISA), and the combination of a negative D-dimer with a low or moderate clinical probability can safely exclude pulmonary embolism in many patients. If pulmonary embolism is not excluded, contrast-enhanced computed tomographic pulmonary angiography (CT angiography) in combination with venous phase imaging (CT venography), is recommended by most PIOPED II investigators, although CT angiography plus clinical assessment is an option. In pregnant women, ventilation/perfusion scans are recommended by many as the first imaging test following D-dimer and perhaps venous ultrasound. In patients with discordant findings of clinical assessment and CT angiograms or CT angiogram/CT venogram, further evaluation may be necessary.

Conclusion

The sequence for diagnostic test in patients with suspected pulmonary embolism depends on the clinical circumstances.

Keywords: Pulmonary embolism, Venous thromboembolism, Computed tomographic angiography, D-dimer, Pulmonary scintigraphy, Clinical assessment

 

 Supported by Grants HL63899, HL63928, HL63931, HL063932, HL63940, HL63941, HL63942, HL63981, HL63982, and HL67453 from the U.S. Department of Health and Human Services, Public Health Services, National Heart, Lung, and Blood Institute, Bethesda, MD.Diagnostic Pathways in Acute Pulmonary Embolism: Recommendations of the PIOPED II Investigators by Stein et al is being jointly published by The American Journal of Medicine and Radiology. A similar article will appear as an editorial in the January 2007 issue of Radiology.

PII: S0002-9343(06)00779-0

doi:10.1016/j.amjmed.2006.05.060

The American Journal of Medicine
Volume 119, Issue 12 , Pages 1048-1055, December 2006

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