Annals of Emergency Medicine
Volume 35, Issue 2 , Pages 168-180 , February 2000

New diagnostic tests for pulmonary embolism

  • Jeffrey A. Kline, MD

      Affiliations

    • Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC
    • ,
  • Kathryn L. Johns, MD

      Affiliations

    • Department of Emergency Medicine, Eastern Virginia School of Medicine, Norfolk, VA
    • ,
  • Stephen A. Colucciello, MD

      Affiliations

    • Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC
    • ,
  • Elizabeth G. Israel, MD, DVM

      Affiliations

    • Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO.

Received 22 January 1999 ,Revised 26 July 1999 ,Accepted 7 September 1999.

References 

  1. PIOPED . Value of the ventilation/perfusion scan in acute pulmonary embolism: results of the prospective investigation of pulmonary embolism diagnosis. JAMA. 1990;263:2753–2759
  2. Worsley DF, Alavi A. Comprehensive analysis of the results of the PIOPED Study. J Nucl Med. 1995;36:2380–2387
  3. Irwig LI, Tossteson ANA, Gatsonis C, et al.  Guidelines for meta-analyses evaluating diagnostic tests. Ann Intern Med. 1994;120:667–676
  4. DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7:177–188
  5. Kline J, Meek S, Boudrow D, et al.  Use of the alveolar dead space fraction (Vd/Vt) and plasma D -dimers to exclude acute pulmonary embolism in ambulatory patients. Acad Emerg Med. 1997;4:856–863
  6. Wells PS, Ginsberg JS, Anderson DR, et al.  Use of a clinical model for safe management of patients with suspected pulmonary embolism. Ann Intern Med. 1998;129:997–1005
  7. Hull RD, Raskob GE, Carter CJ, et al.  Pulmonary embolism in outpatients with pleuritic chest pain. Arch Intern Med. 1988;148:838–844
  8. Kline JA, Arunachlam M. Preliminary study of the capnogram waveform area to screen for pulmonary embolism. Ann Emerg Med. 1998;32:289–296
  9. Patil S, Henry JW, Rubenfire M, et al.  Neural network in the clinical diagnosis of acute pulmonary embolism. Chest. 1993;104:1685–1689
  10. Devine DV, Greenberg CS. Monoclonal antibody to fibrin D -dimer (DD-3B6) recognizes an epitope on the gamma chain of fragment D. Am J Clin Pathol. 1988;89:663–666
  11. Greenberg CS, Devine DV, McCrae KM. Measurement of plasma fibrin D -dimer levels with the use of a monoclonal antibody coupled to latex beads. Am J Clin Pathol. 1987;87:94–100
  12. Rowbotham BJ, Vernon JE, Whitaker AN, et al.  Plasma cross linked fibrin degradation products in pulmonary embolism. Thorax. 1990;45:684–687
  13. Oger E, Leroyer C, Bressollette L, et al.  Evaluation of a new, rapid, and quantitative D -dimer test in patients with suspected pulmonary embolism. Am J Respir Crit Care Med. 1998;158:65–70
  14. Goldhaber SZ, Simons GR, Elliott G, et al.  Quantitative plasma D -dimer levels among patients undergoing pulmonary angiography for suspected pulmonary embolism. JAMA. 1993;270:2819–2822
  15. Goldhaber SZ, Vaughn DE, Tumeh SS, et al.  Utility of cross-linked fibrin degradation products in the diagnosis of pulmonary embolism. Am Heart J. 1988;116:505–508
  16. Elms MJ, Bunce IH, Bundesen PG, et al.  Rapid detection of cross-linked fibrin degradation products in plasma using monoclonal antibody-coated latex particles. J Clin Pathol. 1986;85:360–364
  17. Whitaker AN, Elms MJ, Masci PP, et al.  Measurement of cross linked fibrin derivatives in plasma: an immunoassay using monoclonal antibodies. J Clin Pathol. 1984;37:882–887
  18. Bounameaux H, Schneider PA, Reber G, et al.  Measurement of plasma D -dimer for diagnosis of deep venous thrombosis. Am J Clin Pathol. 1989;91:82–85
  19. Ginsberg JS, Brill-Edwards PA, Demers C, et al.  D -dimer in patients with clinically suspected pulmonary embolism. Chest. 1993;104:1679–1684
  20. Leitha T, Speiser W, Dudscak R. Pulmonary embolism: efficacy of D -dimer and thrombolic-antithrombolic III complex determinations as screening tests before lung scanning. Chest. 1991;100:1536–1541
  21. Dale S, Gogstadd GO, Brosstad F, et al.  Comparison of three D -dimer assays for the diagnosis of DVT: ELISA, latex and an immunofiltration assay (NycoCard D -dimer). Thromb Haemost. 1994;71:270–274
  22. Scarano L, Bemardi E, Prandoni P, et al.  Accuracy of two newly described D -dimer tests in patients with suspected deep venous thrombosis. Thromb Res. 1997;86:93
  23. Janssen MCH, Heebels AE, de Metz M, et al.  Reliability of five rapid D -dimer assays compared to ELISA in the exclusion of deep venous thrombosis. Thromb Haemost. 1997;77:262–266
  24. Veitl M, Hamwi A, Kurtaran A, et al.  Comparison of four rapid D -dimer tests for diagnosis of pulmonary embolism. Thromb Res. 1996;82:399–407
  25. Leroyer C, Escoffre M, LeMoigne EL, et al.  Diagnostic value of a new sensitive membrane based technique for instantaneous D -dimer evaluation in patients with clinically suspected deep venous thrombosis. Thromb Haemost. 1997;77:637–640
  26. Hansson PO, Eriksson H, Eriksson E, et al.  Can laboratory testing improve screening strategies for deep vein thrombosis at an emergency unit?. J Intern Med. 1994;235:143–151
  27. Kozman H, Flemmer MC, Rahnama M. Deep venous thrombosis: prediction by D -dimer?. South Med J. 1997;90:907–910
  28. Bongard O, Wicky J, Peter R, et al.  D -dimer plasma measurement in patients undergoing major hip surgery: use in the prediction and diagnosis of postoperative proximal vein thrombosis. Thromb Res. 1994;74:487–493
  29. Freyburger G, Trillaud H, Labrouche S, et al.  D-dimer strategy in thrombosis exculsion—a gold standard study in 100 patients suspected of deep venous thrombosis or pulmonary embolism: 8 DD methods compared. Thromb Haemost. 1998;79:32–37
  30. Wildberger JE, Vorwerk D, Kilbinger M, et al.  Bedside testing (SimpliRED) in the diagnosis of deep vein thrombosis: evaluation of 250 patients. Invest Radiol. 1998;33:232–235
  31. Wells PS, Anderson DR, Bormanis J, et al.  SimpliRED D -dimer can reduce the diagnostic tests in suspected deep vein thrombosis. Lancet. 1998;351:1405–1406
  32. Ginsberg JS, Kearon C, Douketis J, et al.  The use of D -dimer testing and impedance plethysmographic examination in patients with clinical indications of deep venous thrombosis. Arch Intern Med. 1997;157:1077–1081
  33. Mayer W, Hirschwehr R, Hippmann G, et al.  Whole-blood immunoassay (SimpliRED) versus plasma immunoassay (NycoCard) for the diagnosis of clinically suspected deep vein thrombosis. VASA. 1997;26:97–101
  34. D’Angelo A, D’Alessandro G, Tomassini L, et al.  Evaluation of a new rapid quantitative D -dimer assay in patients with clinically suspected deep vein thrombosis. Thromb Haemost. 1996;75:412–416
  35. Reber G, de Moerloose P, Coquoz C, et al.  Comparison of two rapid D -dimer assays for the exclusion of venous thromboembolism. Blood Coagul Fibrinolysis. 1998;9:387–388
  36. Perrier A, Desmarais S, Miron M-J, et al.  Non-invasive diagnosis of venous thromboembolism in outpatients. Lancet. 1999;353:190–195
  37. Bemardi E, Prandoni P, Lensing AWA, et al.  D -dimer testing as an adjunct to ultrasonography in patients with clinically suspected deep vein thrombosis: prospective cohort study. BMJ. 1998;317:1037–1040
  38. van Beek EJR, Schenk BE, Michel BC, et al.  The role of D -dimer concentration in the exclusion of pulmonary embolism. Br J Haematol. 1996;92:725–732
  39. Quinn RJ, Nour R, Butler SP, et al.  Pulmonary embolism in patients with intermediate probability lung scans: diagnosis with Doppler venous US and D -dimer measurement. Radiology. 1994;190:509–511
  40. Perrier A, Desmarais S, Goeshring C, et al.  D -dimer testing for suspected pulmonary embolism in outpatients. Am J Respir Crit Care Med. 1997;156:492–496
  41. Perrier A, Bounameaux H, Morabia A, et al.  Diagnosis of pulmonary embolism by a decision analysis-based strategy including clinical probability, D -dimer levels, and ultrasonography: a management study. Arch Intern Med. 1996;156:531–536
  42. Bonnin F, Hadjikosstova H, Jebrak G, et al.  Complementarity of lung scintigraphy and D -dimer test in pulmonary embolism. Eur J Nucl Med. 1997;24:444–447
  43. Tardy B, Tardy-Poncet B, Viallon A, et al.  Evaluation of D -dimer ELISA test in elderly patients with suspected pulmonary embolism. Thromb Haemost. 1998;79:38–41
  44. Turkstra F, van Beek EJR, ten Cate JW, et al.  Reliable, rapid blood test for the exclusion of venous thromboembolism in symptomatic outpatients. Thromb Haemost. 1996;76:9–11
  45. Ginsberg JS, Wells PS, Brill-Edwards P, et al.  Application of a novel and rapid whole blood assay for D -dimer in patients with clinically suspected pulmonary embolism. Thromb Haemost. 1995;73:35–38
  46. Egermayer P, Town Gl, Turner JG, et al.  Usefulness of D -dimer, blood gas and respiratory rate measurements for excluding pulmonary embolism. Thorax. 1998;53:830–834
  47. Ginsberg JS, Wells PS, Kearon C, et al.  Sensitivity and specificity of a rapid whole-blood assay for D -dimer in the diagnosis of pulmonary embolism. Ann Intern Med. 1998;129:1006–1011
  48. Duet M, Benelhadj S, Kedra W, et al.  A new quantitative D -dimer assay appropriate in emergency: reliability of the assay for pulmonary embolism exclusion diagnosis. Thromb Res. 1998;91:1–5
  49. de Moerloose P, Desmarais S, Bounameaux H, et al.  Contribution of a new, rapid, individual and quantitative automated D -dimer ELISA to exclude pulmonary embolism. Thromb Haemost. 1996;75:11–13
  50. Turkstra F, van Beek EJR, Buller HR. Observer and biological variation of a rapid whole blood D -dimer test. Thromb Haemost. 1998;79:91–93
  51. Dantzker DR, Wagner PD, Tomabene VW, et al.  Gas exchange after pulmonary thromboembolization in dogs. Circ Res. 1978;42:92–103
  52. Haire WD. Pharmacology of fibrinolysis. Chest. 1992;101:91S–97S
  53. Swenson EW, Finley TN, Guzman SV. Unilateral hypoventilation in man during temporary occlusion of one pulmonary artery. J Clin Invest. 1960;40:828–835
  54. Fletcher R, Jonson B. Deadspace and the single breath test for carbon dioxide during anaesthesia and artificial ventilation. Br J Anesth. 1994;56:109–119
  55. Eriksson L, Wollmer P, Olsson C, et al.  Diagnosis of pulmonary embolism based upon alveolar dead space analysis. Chest. 1989;96:357–362
  56. Burki NK. The dead space to tidal volume ratio in the diagnosis of pulmonary embolism. Am Rev Respir Dis. 1986;133:679–685
  57. Olsson K, Jonson B, Olsson CG, et al.  Diagnosis of pulmonary embolism by measurement of alveolar dead space. J Intern Med. 1998;244:199–207
  58. Vereerstraeten J, Schoutens A, Tombroff M, et al.  Value of measurement of alveolar-arterial gradient of PCO2 compared to pulmonary scan in diagnosis of thromboembolic pulmonary disease. Thorax. 1973;28:306–312
  59. Nikodymova L, Daum S, Stiksa J, et al.  Respiratory changes in thromboembolic disease. Respiration. 1968;25:51–66
  60. Jones NL, Goodwin JF. Respiratory function in pulmonary thromboembolic disorders. BMJ. 1965;1:1089–1093
  61. MacKeen AD, Landrigan PL, Dickson RC. Early diagnosis of pulmonary embolism. Can Med Assoc J. 1961;85:233–236
  62. Kline JA, Kubin AK, Patel MM, et al. Alveolar deadspace as a predictor of severity of pulmonary embolism. Acad Emerg Med . In press.
  63. Jones JS, VanDeelen N, White L, et al.  Alveolar-arterial oxygen gradients in elderly patients with suspected pulmonary embolism. Ann Emerg Med. 1993;22:1177–1181
  64. Jones JS, Neff TL, Carlson SA. Use of the alveolar-arterial oxygen gradient in the assessment of acute pulmonary embolism. Am J Emerg Med. 1998;16:333–337
  65. Stein PD, Goldhaber SZ, Henry JW, et al.  Arterial blood gas analysis in the assessment of suspected acute pulmonary embolism. Chest. 1996;109:78–81
  66. Stein PD, Goldhaber SZ, Henry JW. Alveolar-arterial oxygen gradient in the assessment of acute pulmonary embolism. Chest. 1995;107:139–143
  67. McFarlane MJ, Imperiale TF. Use of the alveolar-arterial oxygen gradient in the diagnosis of pulmonary embolism. Am J Med. 1994;96:57–62
  68. Cvitanic O, Marino PL. Improved use of arterial blood gas analysis in suspected pulmonary embolism. Chest. 1989;95:48–51
  69. Ferretti GR, Bosson JL, Buffaz PD, et al.  Acute pulmonary embolism: role of helical CT in 164 patients with intermediate probability at ventilation-perfusion scintigraphy and normal results at duplex US of the legs. Radiology. 1997;205:453–458
  70. Remy-Jardin M, Remy J, Deschildre F, et al.  Diagnosis of pulmonary embolism with spiral CT: comparison with pulmonary angiography and scintigraphy. Radiology. 1996;200:699–706
  71. Goodman LR, Curtin JJ, Mewissen MW, et al.  Detection of pulmonary embolism in patients with unresolved clinical and scintigraphic diagnosis: helical CT versus angiography. AJR Am J Roentgenol. 1995;164:1369–1374
  72. Goodman LR. CT of acute pulmonary emboli: where does it fit?. Radiographics. 1997;17:1037–1042
  73. Blum AG, Delfau F, Grignon B, et al.  Spiral-computed tomography versus pulmonary angiography in the diagnosis of acute massive pulmonary embolism. Am J Cardiol. 1994;74:96–98
  74. Pruszczyk P, Torbicki A, Pacho R, et al.  Noninvasive diagnosis of suspected severe pulmonary embolism. Chest. 1997;112:722–728
  75. Mayo JR, Remy-Jardin M, Muller NL, et al.  Pulmonary embolism: prospective comparison of spiral CT with ventilation-perfusion scintigraphy. Thorac Radiol. 1997;205:447–452
  76. Russi TJ, Libby DM, Henschke CI. Clinical utility of computed tomography in the diagnosis of pulmonary embolism. Clin Imaging. 1997;21:175–182
  77. Remy-Jardin M, Remy J, Cauvain O, et al.  Diagnosis of central pulmonary embolism with helical CT: role of two-dimensional multiplanar reformations. AJR Am J Roentgenol. 1995;165:1131–1138
  78. Beigelman C, Chartrand-Lefebvre C, Howarth N, et al.  Pitfalls in diagnosis of pulmonary embolism with helical CT angiography. AJR Am J Roentgenol. 1998;171:579–585
  79. Remy-Jardin M, Remy J, Artaud D, et al.  Peripheral pulmonary arteries: optimization of the spiral CT acquisition protocol. Thorac Radiol. 1997;204:157–163
  80. Tiegen CL, Maus TP, Sheedy PF, et al.  Pulmonary embolism: diagnosis with electron beam CT. Radiology. 1993;188:839–845
  81. Teigen CL, Maus TP, Sheedy PF, et al.  Pulmonary embolism: diagnosis with contrast-enhanced electron-beam CT and comparison with pulmonary angiography. Radiology. 1995;194:313–319
  82. Garg K, Welsch CH, Feyerabend AJ, et al.  Pulmonary embolism: diagnosis with spiral CT and ventilation-perfusion scanning—correlation with pulmonary angiographic results or clinical outcome. Radiology. 1998;208:201–208
  83. Remy-Jardin M, Remy J, Wattinne L, et al.  Central pulmonary thromboembolism: diagnosis with spiral volumetric CT with single breath-hold technique—comparison with pulmonary angiography. Radiology. 1992;185:381–387
  84. Drucker EA, Rivitz SM, Shepard JO, et al.  Acute pulmonary embolism: assessment of helical CT for diagnosis. Radiology. 1998;209:235–241
  85. Sostman HD, Layish DT, Tapson VF, et al.  Prospective comparison of helical CT and MR imaging in clinically suspected acute pulmonary embolism. J Magn Reson Imaging. 1996;6:275–281
  86. van Rossum AB, Treurniet FEE, Kieft GJ, et al.  Role of spiral volumetric computed tomographic scanning in the assessment of patients with clinical suspicion of pulmonary embolism and an abnormal ventilation-perfusion lung scan. Thorax. 1996;51:23–28
  87. van Rossum AB, Pattynama PMT, Ton ERTA, et al.  Pulmonary embolism: validation of spiral CT angiography in 149 patients. Radiology. 1996;201:467–470
  88. Dresel S, Stabler A, Scheidler J, et al.  Diagnostic approach in acute pulmonary embolism: perfusion scintigraphy versus spiral computed tomography. Nucl Med Commun. 1995;16:1009–1015
  89. Cross JJL, Kemp PM, Walsh CG, et al.  A randomized trial of spiral CT and ventilation perfusion scintigraphy for the diagnosis of pulmonary embolism. Clin Radiol. 1998;53:177–182
  90. Remy-Jardin M, Remy J, Louvegny S, et al.  Airway changes in chronic pulmonary embolism: CT findings in 33 patients. Thorac Radiol. 1997;203:355–360
  91. Coche EE, Muller NL, Kim KI, et al.  Acute pulmonary embolism: ancillary findings at spiral CT. Radiology. 1998;207:753–758
  92. Diffin DC, Leyendecker JR, Johnson SP, et al.  Effect of anatomic distribution of pulmonary emboli on interobserver agreement in the interpretation of pulmonary angiography. AJR Am J Roentgenol. 1998;171:1085–1089
  93. Stein PD, Goldhaber SZ, Gottschalk A, et al.  Opinions/hypotheses: opinions regarding the diagnosis and management of venous thromboembolic disease. Chest. 1998;113:499–504
  94. van Rossum AB, van Erkel AR, van Persijn van Meerten EL, et al.  Accuracy of helical CT for acute pulmonary embolism: ROC analysis of observer performance related to clinical experience. Eur Radiol. 1998;8:1160–1164
  95. Chartrand-Lefebvre C, Howarth N, Lucidarme O, et al.  Contrast-enhanced helical CT for pulmonary embolism detection: inter- and intraobserver agreement among radiologists with variable experience. AJR Am J Roentgenol. 1999;172:107–112
  96. van Erkel AR, van Rossum AB, Bloem JL, et al.  Spiral CT angiography for suspected pulmonary embolism: a cost-effectiveness analysis. Radiology. 1996;201:29–36
  97. Goldberg SN, Palmer EL, Scott JA, et al.  Pulmonary embolism: prediction of the usefulness of initial ventilation-perfusion scanning with chest radiographic findings. Radiology. 1994;193:801–805
  98. Loubeyre P, Revel D, Doucek P, et al.  Dynamic contrast-enhanced MR angiography of pulmonary embolism: comparison with pulmonary angiography. AJR Am J Roentgenol. 1994;162:1035–1039
  99. Meaney JFM, Weg JG, Chenevert TL, et al.  Diagnosis of pulmonary embolism with magnetic resonance angiography. N Engl J Med. 1997;336:1422–1427
  100. Amundsen T, Kvaemess J, Jones RA, et al.  Pulmonary embolism: detection with MR perfusion imaging of lung—a feasibility study. Radiology. 1997;203:181–185
  101. Bergin CJ, Sirlin CB, Haudschildt JP, et al.  Chronic thromboembolism: diagnosis with helical CT and MR imaging with angiographic and surgical correlation. Radiology. 1997;204:695–702
  102. Kauczor H-U. Contrast-enhanced magnetic resonance angiography of the pulmonary vasculature. Invest Radiol. 1998;33:606–617
  103. Erdman WA, Peshock RM, Redman HC, et al.  Pulmonary embolism: comparison of MR images with radionuclide and angiographic studies. Radiology. 1994;190:499–508
  104. Grist TM, Sostman HD, MacFall JR, et al.  Pulmonary angiography with MR imaging: preliminary clinical experience. Radiology. 1993;189:523–530
  105. Laissy JP, Bancal C, Sekkal S, et al.  Pulmonary MR angiography at 110 T: early results with s-space segmented and post-contrast TurboFLASH two-dimensional time-of-flight sequences. Eur J Radiol. 1995;20:9–15
  106. Hatabu H, Gefter WB, Axel L, et al.  MR imaging with spatial modulation of magnetization in the evaluation of chronic central pulmonary thromboemboli. Radiology. 1994;190:791–796
  107. Vieillard-Baron A, Qanadli SD, Antakly Y, et al.  Transesophageal echocardiography for the diagnosis of pulmonary embolism with acute cor pulmonale: a comparison with radiologic procedures. Intensive Care Med. 1998;24:429–433
  108. Barton CW, Eisenberg MJ, Schiller N. Transesophageal echocardiographic diagnosis of massive pulmonary embolism during cardiopulmonary resuscitation. Am Heart J. 1994;127:1639–1642
  109. Rudoni RR, Jackson RE, Godfrey GW, et al.  Use of two dimensional echocardiography for the diagnosis of pulmonary embolus. J Emerg Med. 1998;16:5–8
  110. Wolfe MW, Lee RT, Feldstein ML, et al.  Prognostic significance of right ventricular hypokinesis and perfusion lung scan defects in pulmonary embolism. Am Heart J. 1994;127:1371–1375
  111. Torbicki A, Trmnarin R, Morpurgo M. Role of echo/Doppler in the diagnosis of pulmonary embolism. Clin Cardiol. 1992;15:805–810
  112. Pruszczyk P, Torbicki A, Kugh-Wocial A, et al.  Transesophageal echocardiography for definitive diagnosis of haemodynamically significant pulmonary embolism. Eur Heart J. 1995;16:534–538
  113. Steiner P, Lund GK, Debatin JF, et al.  Acute pulmonary embolism: value of transthoracic and transesophageal echocardiography in comparison with helical CT. AJR Am J Roentgenol. 1996;167:931–936
  114. Perrier A, Tamm C, Unger PF, et al.  Diagnostic accuracy of Doppler-echocardiography in unselected patients with suspected pulmonary embolism. Int J Cardiol. 1998;65:101–109
  115. Nazeyrollas P, Getz D, Maillier B, et al.  Use of transthoracic Doppler echocardiography combined with clinical and electrocardiographic data to predict acute pulmonary embolism. Eur Heart J. 1996;17:779–786
  116. Nazeyrollas P, Metz D, Chapoutot L, et al.  Diagnostic accuracy of echocardiography-Doppler in acute pulmonary embolism. Int J Cardiol. 1995;47:273–280
  117. Nakayama Y, Sugimachi M, Nakanishi N, et al.  Noninvasive differential diagnosis between chronic pulmonary thromboembolism and primary pulmonary hypertension by means of Doppler ultrasound measurement. J Am Coll Cardiol. 1998;31:1367–1371
  118. Cheriex EC, Sreeram N, Pieters FAA, et al.  Cross sectional Doppler echocardiography as the initial technique for the diagnosis of acute pulmonary embolism. Br Heart J. 1994;72:52–57
  119. Kasper W, Meinertz T, Henkel B, et al.  Echocardiographic findings in patients with proved pulmonary embolism. Am Heart J. 1986;112:1284–1290
  120. Wittlich N, Erbe R, Eichler A, et al.  Detection of central pulmonary artery thromboemboli by transesophageal echocardiography in patients with severe pulmonary embolism. J Am Soc Echocardiogr. 1992;5:515–524
  121. Grifoni S, Olivotto I, Cecchini P, et al.  Utility of an integrated clinical, echocardiographic and venous ultrasonographic triage of patients with suspected pulmonary embolism. Am J Cardiol. 1998;82:1230–1235
  122. Susec O, Boudrow D, Kline J. The clinical features of acute pulmonary embolism in ambulatory patients. Acad Emerg Med. 1997;4:891–897
  123. Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the international cooperative pulmonary embolism registry (ICOPER). Lancet. 1999;353:1386–1389
  124. Manganelli D, Palla A, Donnamaria V, et al.  Clinical features of pulmonary embolism: doubts and certainties. Chest. 1995;107:25S–32S

☆ None of the authors have received funds from any private or public source for the explicit purpose of writing this article.

☆☆ Two of the authors (JAK, EGI) are engaged in a multicenter trial involving the use of dead space and SimpliRED D -dimer measurements to screen for pulmonary embolism, the Rapid Exclusion of Pulmonary Embolism (REPE) study. The authors’ institutions receive a $100 stipend for each patient enrolled in the REPE study.

★ Address for reprints: Jeffrey Kline, MD, Department of Emergency Medicine, MEB 304, Carolinas Medical Center, Charlotte, NC 28232-2861; 704-355-7092, fax 704-355-7047; E-mail Jkline@carolinas.org.

PII: S0196-0644(00)70137-5

Annals of Emergency Medicine
Volume 35, Issue 2 , Pages 168-180 , February 2000

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