Annals of Emergency Medicine
Volume 55, Issue 4 , Pages 316-326.e1 , April 2010

Testing Low-Risk Patients for Suspected Pulmonary Embolism: A Decision Analysis

Presented at the Society for Academic Emergency Medicine annual meeting, May 2009, New Orleans, LA.

  • Adam L. Lessler, BA

      Affiliations

    • Department of Emergency Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA
    • Corresponding Author InformationAddress for correspondence: Adam L. Lessler, 917-612-9620
  • ,
  • Joshua A. Isserman, MS

      Affiliations

    • Department of Emergency Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA
  • ,
  • Rajan Agarwal, MD, MBA

      Affiliations

    • Department of Radiology, University of Pennsylvania School of Medicine, Philadelphia, PA
  • ,
  • Harold I. Palevsky, MD

      Affiliations

    • Allergy and Critical Care Division, University of Pennsylvania School of Medicine, Philadelphia, PA
  • ,
  • Jesse M. Pines, MD, MBA, MSCE

      Affiliations

    • Department of Emergency Medicine, George Washington University School of Medicine and the Department of Health Policy, and School of Public Health and Health Services, Washington, DC

Received 28 June 2009 ,Revised 22 November 2009 ,Accepted 2 December 2009.

References 

  1. Hull RD, Pineo GF, Stein PD, et al. Cost-effectiveness of currently accepted strategies for pulmonary embolism diagnosis. Semin Thromb Hemost. 2001;27:15–23
  2. Paterson DI, Schwartzman K. Strategies incorporating spiral CT for the diagnosis of acute pulmonary embolism: a cost-effectiveness analysis. Chest. 2001;119:1791–1800
  3. Perrier A, Nendaz MR, Sarasin FP, et al. Cost-effectiveness analysis of diagnostic strategies for suspected pulmonary embolism including helical computed tomography. Am J Respir Crit Care Med. 2003;167:39–44
  4. Pitts SR, Niska RW, Xu J, et al. National Hospital Ambulatory Medical Care Survey: 2006 emergency department summary. Natl Health Stat Rep. 2008;7:1–38
  5. Hirsh J, Hoak J Council on Thrombosis (in consultation with the Council on Cardiovascular Radiology), American Heart Association. Management of deep vein thrombosis and pulmonary embolism (A statement for healthcare professionals). Circulation. 1996;93:2212–2245
  6. Begemann PG, Bonacker M, Kemper J, et al. Evaluation of the deep venous system in patients with suspected pulmonary embolism with multi-detector CT: a prospective study in comparison to Doppler sonography. J Comput Assist Tomogr. 2003;27:399–409
  7. Rademaker J, Griesshaber V, Hidajat N, et al. Combined CT pulmonary angiography and venography for diagnosis of pulmonary embolism and deep vein thrombosis: radiation dose. J Thorac Imaging. 2001;16:297–299
  8. Remy-Jardin M, Pistolesi M, Goodman LR, et al. Management of suspected acute pulmonary embolism in the era of CT angiography: a statement from the Fleischner Society. Radiology. 2007;245:315–329
  9. Amis J, Stephen E, Butler PF, et al. American College of Radiology white paper on radiation dose in medicine. J Am Coll Radiol. 2007;4:272–284
  10. Einstein AJ, Henzlova MJ, Rajagopalan S. Estimating risk of cancer associated with radiation exposure from 64-slice computed tomography coronary angiography. JAMA. 2007;298:317–323
  11. Brenner DJ, Hall EJ. Computed tomography—an increasing source of radiation exposure. N Engl J Med. 2007;357:2277–2284
  12. Cochran ST, Bomyea K, Sayre JW. Trends in adverse events after IV administration of contrast media. AJR Am J Roentgenol. 2001;176:1385–1388
  13. Calder KK, Herbert M, Henderson SO. The mortality of untreated pulmonary embolism in emergency department patients. Ann Emerg Med. 2005;45:302–310
  14. Stein PD, Henry JW, Relyea B. Untreated patients with pulmonary embolism (Outcome, clinical, and laboratory assessment). Chest. 1995;107:931–935
  15. Smith R, Maher JM, Miller RI, et al. Clinical outcomes of patients with suspected pulmonary embolism and low-probability aerosol-perfusion scintigrams. Radiology. 1987;164:731–733
  16. Rajendran JG, Jacobson AF. Review of 6-month mortality following low-probability lung scans. Arch Intern Med. 1999;159:349–352
  17. Lee ME, Biello DR, Kumar B, et al. “Low-probability” ventilation-perfusion scintigrams: clinical outcomes in 99 patients. Radiology. 1985;156:497–500
  18. Nielsen HK, Husted SE, Krusell LR, et al. Silent pulmonary embolism in patients with deep venous thrombosis (Incidence and fate in a randomized, controlled trial of anticoagulation versus no anticoagulation). J Intern Med. 1994;235:457–461
  19. Kahn D, Bushnell DL, Dean R, et al. Clinical outcome of patients with a “low probability” of pulmonary embolism on ventilation-perfusion lung scan. Arch Intern Med. 1989;149:377–379
  20. Donato AA, Scheirer JJ, Atwell MS, et al. Clinical outcomes in patients with suspected acute pulmonary embolism and negative helical computed tomographic results in whom anticoagulation was withheld. Arch Intern Med. 2003;163:2033–2038
  21. Le Gal G, Righini M, Parent F, et al. Diagnosis and management of subsegmental pulmonary embolism. J Thromb Haemost. 2006;4:724–731
  22. Segal JB, Eng J, Tamariz LJ, et al. Review of the evidence on diagnosis of deep venous thrombosis and pulmonary embolism. Ann Fam Med. 2007;5:63–73
  23. Schulman S, Beyth RJ, Kearon C, et al. American College of Chest Physicians Hemorrhagic complications of anticoagulant and thrombolytic treatment: American College of Chest Physicians evidence-based clinical practice guidelines (8th edition). Chest. 2008;133(6 suppl):257S–298S
  24. Wells PS, Forgie MA, Simms M, et al. The outpatient bleeding risk index: validation of a tool for predicting bleeding rates in patients treated for deep venous thrombosis and pulmonary embolism. Arch Intern Med. 2003;163:917–920
  25. Kline JA, Mitchell AM, Kabrhel C, et al. Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism. J Thromb Haemost. 2004;2:1247–1255
  26. Wolf SJ, McCubbin TR, Nordenholz KE, et al. Assessment of the Pulmonary Embolism Rule-out Criteria rule for evaluation of suspected pulmonary embolism in the emergency department. Am J Emerg Med. 2008;26:181–185
  27. Kline JA, Courtney DM, Kabrhel C, et al. Prospective multicenter evaluation of the Pulmonary Embolism Rule-out Criteria. J Thromb Haemost. 2008;6:772–780
  28. Pauker SG, Kassirer JP. The threshold approach to clinical decision making. N Engl J Med. 1980;302:1109–1117
  29. Zhu T, Martinez I, Emmerich J. Venous thromboembolism: risk factors for recurrence. Arterioscler Thromb Vasc Biol. 2009;29:298–310
  30. Mitchell AM, Kline JA. Contrast nephropathy following computed tomography angiography of the chest for pulmonary embolism in the emergency department. J Thromb Haemost. 2007;5:50–54
  31. Stein PD, Hull RD, Patel KC, et al. D-dimer for the exclusion of acute venous thrombosis and pulmonary embolism: a systematic review. Ann Intern Med. 2004;140:589–602
  32. Stein PD, Fowler SE, Goodman LR, et al. Multidetector computed tomography for acute pulmonary embolism. N Engl J Med. 2006;354:2317–2327
  33. Mitchell AM, Jones AE, Tumlin JA, et al. Incidence of contrast-induced nephropathy after contrast-enhanced computed tomography in the outpatient setting. Clin J Am Soc Nephrol. In press.
  34. Pierce DA, Preston DL. Radiation-related cancer risks at low doses among atomic bomb survivors. Radiat Res. 2000;154:178–186
  35. Tengs TO, Wallace A. One thousand health-related quality-of-life estimates. Med Care. 2000;38:583–637
  36. Arias E. United states life tables, 2004. Natl Vital Stat Rep. 2007;56:1–39
  37. In:  Gold MR,  Siegel JE,  Russell LB, et al. editor. Cost-Effectiveness in Health and Medicine. New York, NY: Oxford University Press; 1996;
  38. Freeman LM, Stein EG, Sprayregen S, et al. The current and continuing important role of ventilation-perfusion scintigraphy in evaluating patients with suspected pulmonary embolism. Semin Nucl Med. 2008;38:432–440
  39. Miniati M, Sostman HD, Gottschalk A, et al. Perfusion lung scintigraphy for the diagnosis of pulmonary embolism: a reappraisal and review of the prospective investigative study of acute pulmonary embolism diagnosis methods. Semin Nucl Med. 2008;38:450–461
  40. Barritt DW, Jordan SC. Anticoagulant drugs in the treatment of pulmonary embolism (A controlled trial). Lancet. 1960;1:1309–1312

 Supervising editor: Steven M. Green, MD

 Author contributions: ALL and JMP conceived the study, designed the decision model, and performed the data analysis. RA and HIP provided content advice on the radiology- and pulmonary embolism-specific components, respectively. JAI assisted with the research methodology. ALL drafted the article, and all authors contributed substantially to its revision. ALL takes responsibility for the paper as a whole.

 Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The authors have stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement.

 Publication date: Available online January 9, 2010.

 Earn CME Credit: Continuing Medical Education is available for this article at: www.ACEP-EMedhome.com.

 Reprints not available from the authors.

 Please see page 317 for the Editor's Capsule Summary of this article.

 Provide feedback on this article at the journal's Web site, www.annemergmed.com.

PII: S0196-0644(09)01801-0

doi: 10.1016/j.annemergmed.2009.12.001

Annals of Emergency Medicine
Volume 55, Issue 4 , Pages 316-326.e1 , April 2010