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Semin Vasc Med 2002; 02(4): 345-352
DOI: 10.1055/s-2002-36764
EDITORIAL

Copyright © 2002 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel.: +1(212) 584-4662

The Rehabilitation of Clinical Assessment for the Diagnosis of Pulmonary Embolism

Jan Jacques Michiels1 , Ari  Berghout3 , Wilfried Schroyens1 , Wilfried De Backer2 , Henk Hoogsteden4 , Peter M.T. Pattynama5
  • 1Hemostasis Thrombosis, Department of Hematology, University Hospital, Antwerp, Belgium
  • 2Department of Pulmonary Diseases, University Hospital, Antwerp, Belgium
  • 3Department of Internal Medicine, Medical Center, Rotterdam South
  • 4Department of Pulmonary Diseases, Academic Hospital Dijkzigt, Erasmus University medical Center, Rotterdam, The Netherlands
  • 5Department of Radiology, Academic Hospital Dijkzigt, Erasmus University Medical Center, Rotterdam, The Netherlands
Further Information

Publication History

Publication Date:
22 January 2003 (online)

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ABSTRACT

Pulmonary angiography is the gold standard for diagnosis of segmental pulmonary embolism, but no longer for subsegmental pulmonary embolism because the inter-observer agreement for angiographically documented subsegmental pulmonary embolism is only 60%. A normal rapid ELISA VIDAS D-dimer test result and a normal perfusion scan exclude pulmonary embolism with a negative predictive value of >99%, irrespective of clinical score.

The positive predictive value for pulmonary embolism of a high probability VP-scan compared to pulmonary angiography is 87% indicating that 13% of patients with a high probability VP-scan do not have pulmonary embolism. The combination of a negative CUS, a low clinical score, and a non-diagnostic VP-scan safely excludes pulmonary embolism. Patients with a non-diagnostic VP-scan, a negative CUS, but a moderate to high clinical score are candidates for pulmonary angiography.

The positive predictive value of helical spiral CT is >95 to 99%. The combination of a negative CUS, a low clinical score, and the presence of a clear alternative diagnosis is predicted to safely exclude pulmonary embolism. Helical spiral CT detects all clinical relevant pulmonary emboli and a large number of alternative diagnoses in symptomatic patients with a non-diagnostic or a high-probability VP-scan. The negative predictive value during 3 months followup after a negative spiral CT for pulmonary embolism in 4 retrospective studies and 1 prospective management study was >99%. Only a small group of patients (1-2%) with a non-diagnostic spiral CT are candidates for pulmonary angiography. Therefore, it is predicted that the spiral CT will replace both VP-scanning and pulmonary angiography to safely exclude or diagnose pulmonary emboli in patients with suspected pulmonary embolism.

KEYWORD

Pulmonary embolism - deep vein thrombosis - venous thromboembolism - ventilation perfusion scan - spiral CT - ELISA D-dimer test - clinical score assessment

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