Challenges in the Diagnosis Acute Pulmonary Embolism

Stein, Paul D.; Sostman, H. Dirk; Bounameaux, Henri; Buller, Harry R.; Chenevert, Thomas L.; Dalen, James E.; Goodman, Lawrence R.; Gottschalk, Alexander; Hull, Russell D.; Leeper, Kenneth V.; Pistolesi, Massimo; Raskob, Gary E.; Wells, Philip S.; Woodard, Pamela K.

doi:10.1016/j.amjmed.2008.02.033

« Previous Next »The American Journal of Medicine
Volume 121, Issue 7 , Pages 565-571, July 2008

Challenges in the Diagnosis Acute Pulmonary Embolism

Paul D. Stein, MD
- Department of Research, St Joseph Mercy Oakland Hospital, Pontiac, Mich
- Department of Medicine, Wayne State University, Detroit, Mich
- Requests for reprints should be addressed to Paul D. Stein, MD, Saint Joseph Mercy Oakland, 44405 Woodward Avenue. Pontiac, MI 48341-5023.
H. Dirk Sostman, MD
- Office of the Dean, Weill Cornell Medical College and Methodist Hospital, Houston, Tex
Henri Bounameaux, MD
- Department of Medicine, University of Geneva, Geneva, Switzerland
Harry R. Buller, MD
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands
Thomas L. Chenevert, PhD
- Department of Radiology, University of Michigan, Ann Arbor
James E. Dalen, MD
- College of Medicine and College of Public Health, University of Arizona, Tucson
Lawrence R. Goodman, MD
- Department of Radiology, Medical College of Wisconsin, Milwaukee
Alexander Gottschalk, MD
- Department of Radiology, Michigan State University, East Lansing
Russell D. Hull, MBBS, MSc
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
Kenneth V. Leeper Jr, MD
- Department of Medicine, Emory University, Atlanta, Ga
Massimo Pistolesi, MD
- Department of Critical Care, University of Florence, Florence, Italy
Gary E. Raskob, PhD
- Department of Epidemiology and Medicine, University of Oklahoma Health Sciences Center, Oklahoma City
Philip S. Wells, MD
- Department of Medicine, University of Ottawa and Ottawa Health Research Institute, Ottawa, Canada
Pamela K. Woodard, MD
- Department of Radiology, Washington University, St Louis, Mo.

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.

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