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Query: UMLS:C0034065 (pulmonary embolism)
 14,979 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

A prospective management decision analysis for the exclusion and diagnosis of pulmonary embolism (PE) based on pre-test clinical probability (PCP) estimation for PE, a rapid ELISA D-dimer test, perfusion lungscan (P-scan), CUS, spiral CT, and pulmonary angiography is proposed. The modified PCP model for PE of Wells et al. allows reasonably accurate classification of patients with no, low, moderate, and high probability for PE. The combined rational use of the evidence-based noninvasive imaging techniques P-scan, CUS, and spiral CT with the rapid ELISA D-dimer test and PCP will reduce the need for invasive pulmonary angiography to perhaps 10 to 15% of patients, who initially presented with suspected PE. A Rational Diagnosis of Pulmonary Embolism (RADIA PE) model is proposed for testing in a large multicenter study of patients with suspected PE.
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PMID:Rational diagnosis of pulmonary embolism (RADIA PE) in symptomatic outpatients with suspected PE: an improved strategy to exclude or diagnose venous thromboembolism by the sequential use of a clinical model, rapid ELISA D-dimer test, perfusion lung scan, ultrasonography, spiral CT, and pulmonary angiography. 976 60

The objective was to evaluate the accuracy of a new full blood rapid D-dimer assay in the diagnosis of suspected deep vein thrombosis (DVT). In 100 consecutive patients with suspected DVT, clinical probability was staged according to a pretest score proposed by Wells. For the determination of plasma D-dimer, heparin and citrate blood samples were drawn, and Cardiac D-dimer, STA-LIA, and Tina-quant tests were performed. Final diagnosis was confirmed either by duplex sonography or ascending venography. DVT was diagnosed in 37%, thrombophlebitis in 10%, and no venous thromboembolism was diagnosed in 52%. In 2% pulmonary embolism was detected and one patient was dismissed before final diagnosis. Cardiac D-dimer assay from citrate tubes showed a sensitivity of 88.6%, a specificity of 54%, a positive predictive value of 57.4%, and a negative predictive value of 87.1%. Nearly identical results were observed with heparin tubes. Corresponding results were 88.6%, 48%, 52.5%, and 85.7% for STA-LIA and 88.6%, 46%, 53.4%, and 85.2% for Tina-quant, respectively. In conclusion, we can say that Cardiac D-dimer is a rapid, whole blood assay with a great potential for clinical use. It can help in diagnosing DVT from citrate as well as heparin tubes with comparable sensitivity, specificity, positive and negative predictive values as STA-LIA and Tina-quant tests.
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PMID:Results of a new rapid d-dimer assay (cardiac d-dimer) in the diagnosis of deep vein thrombosis. 1143 42

The diagnosis of pulmonary embolism (PE) is difficult with many patients treated without the disease or left untreated without an adequate diagnostic work up. Recent advances in PE diagnosis are reviewed. The use of risk stratification in PE diagnosis is strongly recommended and evidence on how it can best be performed summarized. The Ginsberg/Wells stratification rule is recommended currently as the best validated rule. Computed tomographic pulmonary angiography (CTPA) was found to have quite poor sensitivity and to be poorly validated. It is recommended as adequate as a positive test in moderate/high risk groups and an exclusionary test in low risk groups or where an adequate alternative diagnosis is found. For D-Dimer tests the only test with adequate sensitivity and validation in management studies is the VIDASCopyright D-Dimer. This is in low/intermediate risk groups in the ED population. The Simpli-RedCopyright test is also reviewed but is too insensitive for most populations. Echocardiography: this is good in compromised patients as it is a bedside test which when negative virtually excludes PE. If positive in the right setting it has a high positive predictive value. A negative echocardiogram predicts a benign clinical course for PE. The rest of the paper details the authors approach to integrating these new techniques with established algorithms and where progress is likely to occur in the next few years. These include improvements in CTPA (plus the addition of CT venography), new point of care D-Dimer tests, better risk stratification rules and integration of new strategies with artificial neural networks or computerized guidelines.
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PMID:Diagnosing pulmonary embolism: a question of too much choice? 1499 73

The assessment of pretest probability (PTP), with stratification into low-, intermediate- and high-risk groups is an essential initial step in the current diagnostic management of patients with suspected venous thromboembolism (VTE). In combination with additional information, it reduces the need for initial and supplementary imaging, and allows considerable refinement of the posterior probability of VTE following non-invasive imaging. PTP may be assessed either empirically or by using various decision rules or scoring systems, the best known of which are the simplified Wells scores for suspected deep vein thrombosis (DVT) and pulmonary embolism (PE), and the Geneva score for suspected PE. Each of these approaches shows similar directional and categorical accuracy, and has been validated as facilitating clinically useful classification of the PTP, although an overview of data suggests that fewer patients tend to be classified as low PTP when assessed empirically. This group is the most important to identify, as several outcome studies have shown that imaging and treatment are safely obviated in outpatients with suspected DVT or PE who have a low PTP in combination with negative d-dimer testing, a subgroup accounting for up to half of all patients studied. Hence, while probably not of critical importance, the explicit approach offered by scoring systems might be preferred over empirical assessment, particularly when used by more junior staff.
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PMID:The utility of pretest probability assessment in patients with clinically suspected venous thromboembolism. 1294 Oct 28

The objective of this study was to evaluate if D-Dimer PLUS (Dade Behring, USA), a rapid fully automated assay, could be used as an initial screening test in the diagnosis of venous thromboembolism (VTE). Samples from 274 consecutive symptomatic patients with suspected pulmonary embolism (n=229; 79% outpatients, 21% inpatients), deep venous thrombosis (n=37; 84% outpatients, 16% inpatients) or suspected for both complications (n=8) were tested with this D-dimer assay with a Sysmex CA-1500 Coagulation Analyzer. Clinical probability for pulmonary embolism (PE) or deep venous thrombosis (DVT) was staged according to a pretest risk score proposed by Wells. Final diagnosis of PE and/or DVT was established by spiral-computed tomography of the pulmonary arteries or compression ultrasonography, respectively. PE was diagnosed in 13.5% of the patients, whereas DVT was confirmed in 17.7% of the patients. The optimal cut-off value for exclusion of venous thromboembolism was 130 mug/l, and sensitivity, specificity and negative predictive value (NPV) were 95.0% (95% CI: 92.4-97.6), 30.4% (95% CI: 25.0-35.8) and 97.2% (95% CI: 95.2-99.2), respectively. In fact, two patient with PE were missed using D-Dimer PLUS; both cases were outpatients. In conclusion, this assay appears to be safe when implemented in an algorithm based on clinical assessment, D-dimer concentration, and radiological diagnostic techniques to stratify the risk for PE or DVT. However, higher sensitivities and negative predictive values were claimed in the scarce published reports for the D-Dimer PLUS assay than found in this study.
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PMID:Exclusion of venous thromboembolism: evaluation of D-Dimer PLUS for the quantitative determination of D-dimer. 1573 71

Two clinical models have been described to predict the probability of pulmonary embolism: the Canadian (or Wells) model, and the Geneva model. A third model has been developed recently at our institution (the Pisa model). We compared the performance of the 3 models in 215 consecutive patients with suspected pulmonary embolism. The clinical probability predicted by the models was categorized as low, intermediate, or high. In all patients, pulmonary angiography was used as the reference diagnostic standard. In patients with pulmonary embolism, the extent of pulmonary embolization was assessed on the lung scan as an index of disease severity. The prevalence of pulmonary embolism was 43.3%, and the median extent of pulmonary embolization at diagnosis was 39.8% (range, 4.5%-75.3%). The proportions of patients categorized as having low, intermediate, or high probability were, respectively: 12%, 60%, and 28%, for the Geneva model; 30%, 55%, and 15%, for the Wells model; 37%, 37%, and 26% for the Pisa model. The frequencies of pulmonary embolism in the low, intermediate, and high probability categories were, respectively: 50%, 39%, and 49% for the Geneva model; 12%, 54%, and 64% for the Wells model; 5%, 42%, and 98% for the Pisa model. Among patients with pulmonary embolism, there was a strong, positive relation between clinical probability predicted by the Pisa model and the extent of pulmonary embolization. The Pisa model proved more accurate than the 2 other models. It may be useful to physicians in defining precisely the pretest probability of pulmonary embolism.
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PMID:Comparison of 3 clinical models for predicting the probability of pulmonary embolism. 1575 40

Excluding or confirming pulmonary embolism remains a diagnostic challenge. In elderly patients pulmonary embolism is associated with substantial co-morbidity and mortality, and many elderly patients with suspected pulmonary embolism are inpatients. The safety and efficacy of the combination of a clinical probability (CDR) and d-dimer test in excluding pulmonary embolism in this group is unclear. We retrospectively analysed data of two prospective studies of consecutive in-and outpatients with suspected pulmonary embolism. The patients were categorized into three age groups: <65 years, 65-75 years and >75 years. The sensitivity, negative predictive value and the proportion of patients with the combination of a non-high CDR score according to Wells (< or = 4) and a normal d-dimer result were calculated for each group. In 747 consecutive patients with suspected pulmonary embolism, sensitivity and negative predictive value of a non-high CDR and a normal d-dimer result in outpatients (n=538) of all age categories (<65 years, 65-75 years and >75 years) were both 100%. These tests were, however, less reliable for inpatients(n=209), irrespective of their age (sensitivity 91% [ CI: 79-98%], negative predictive value 88 % [CI: 74-96%]. The proportion of both in-and outpatients >75 years with a non-high CDR and a normal d-dimer concentration was only 14%, whereas this was 22% in patients 65-75 years and 41% among in-and outpatients <65 years, respectively. In elderly outpatients the combination of a non-high CDR and a normal d-dimer result is a safe strategy to rule out pulmonary embolism. However, in inpatients this algorithm is not reliable to safely exclude pulmonary embolism. In addition, the proportion of patients >65 years in which this strategy excludes pulmonary embolism is markedly lower compared to younger patients.
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PMID:Diagnostic strategy using a modified clinical decision rule and D-dimer test to rule out pulmonary embolism in elderly in- and outpatients. 1611 5

Certain clinical findings raise the suspicion of pulmonary embolism (PE) and may be useful in selecting patients for further diagnostic testing. Three prediction rules for PE have been described recently: Wells' rule (WR), Geneva rule (GR) and Miniati' rule (MR). The aim of present study is to compare the predictive accuracy of the three methods on the basis of our patients' results. Eighty-five patients admitted to our department with suspicion of PE were included into the study. Sixty-three patients were discharged with the diagnosis of PE, whereas in 22 patients, the initial PE diagnosis was ruled out. The three methods for assessing the clinical probability of PE classified similar proportions of patients into the low, intermediate and high clinical probability categories. The frequencies of PE in each method (WR, GR and MR) were 5%, 64% and 14% in the low category, 90%, 80% and 75% in the intermediate category and 100%, 100% and 94% in the high category (p = 0.001, 0.064, 0.001) respectively. When we compared the performances of WR and GR, including all possible total score values, the area under the ROC curve (AUC) was 0.99 for the WR (p= 0.001) and 0.74 for the GR (p= 0.001). When we used only the three probability categories (low, intermediate, high), AUC was 0.96 for the WR (p= 0.001), 0.64 for the GR (p= 0.04), and 0.7 for the MR (p= 0.005). In conclusion, the present study indicates that clinical assessment is a fundamental step in the diagnostic work-up of PE. The Wells' method performs better than other two methods.
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PMID:[Comparison of three clinical prediction rules among patients with suspected pulmonary embolism]. 1625 84

Pulmonary embolism (PE) is the commonest cause of maternal death in UK. It is a frequently occurring diagnostic challenge. The false negative and false positive rates for the diagnosis of PE are spectacularly high. Undiagnosed PE has a mortality rate as high as 30%, which falls to 2-8% if the condition is diagnosed and treated appropriately. [Rodger M, Wells PS. Diagnosis of pulmonary embolism. Thromb Res 2001;103:v225-38; Guidelines on Diagnosis and Management of Acute Pulmonary Embolism. Task Force on Pulmonary Embolism, European Society of Cardiology. Eur Heart J 2000;21(16):1301-36]. Physiologic changes of pregnancy further complicate the diagnosis of PE. Although the danger of maternal and foetal death secondary to maternal PE and unnecessary anticoagulation far outweighs the risk of radiation involved in scanning, doctors still hesitate to request appropriate investigation because of concern regarding radiation exposure to the foetus and the absence of any clear, updated guideline. Worried parents need to be counselled appropriately before tests to alleviate anxiety and misunderstanding.
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PMID:Investigating suspected pulmonary embolism during pregnancy. 1654 45

The presence and likelihood of an alternative diagnosis to pulmonary embolism is an important variable of the Wells' prediction rule for establishing clinical probability. We assessed whether evoking specific alternative diagnoses would reduce the probability of pulmonary embolism enough to forego further testing. We retrospectively studied a cohort of 965 consecutive patients admitted for suspicion of pulmonary embolism at three medical centers in Europe in whom the presence of an alternative diagnosis at least as likely as pulmonary embolism was recorded before diagnostic testing. We divided the patients into 15 categories of alternative diagnoses evoked. We then assessed the prevalence of pulmonary embolism in each diagnostic category and compared it to the prevalence of pulmonary embolism in a reference group (patients with no alternative diagnosis or a diagnosis less likely than pulmonary embolism). The prevalence of pulmonary embolism in the reference group was 48%. The presence of an alternative diagnosis as or more likely strongly reduced the probability of pulmonary embolism (OR 0.15, 95% CI: 0.1-0.2, p < 0.01). In almost every diagnostic category, the prevalence of pulmonary embolism was much lower than in the reference group with an odds ratio below or near 0.2. Bronchopneumonia (OR 0.4, 95% CI 0.2 to 0.7) and cancer (OR 0.6, 95% CI 0.3 to 1.5) reduced the likelihood of pulmonary embolism to a lower extent. Evoking an alternative diagnosis at least as likely as pulmonary embolism reduces the probability of the disease, but this effect is never large enough to allow ruling it out without further testing, especially when bronchopneumonia or cancer are the alternative diagnoses considered.
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PMID:Influence of specific alternative diagnoses on the probability of pulmonary embolism. 1673 74


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