Vol 7, No 1 (2022)
Original article
Published online: 2022-03-31

open access

Page views 4790
Article views/downloads 303
Get Citation

Connect on Social Media

Connect on Social Media

Is it possible to reduce overutilization of computed tomographic pulmonary angiography in a real-world population with suspected acute pulmonary embolism?

Agnieszka Bylinka12, Oleh Matshiv1, Beata Zwierko2, Marta Dura13, Jacek Budzyński1
Medical Research Journal 2022;7(1):74-81.

Abstract

Introduction: Computed tomographic pulmonary angiography (CTPA) is the basic examination in the diagnosis of acute pulmonary embolism (PE), however, it is overused many times in emergency units. The aim of this study was to assess the percentage of CTPA which is possible to avoid in patients considered for radiological imaging due to suspected PE.

Material and methods: The retrospective analysis of clinical data and the calculation of PE probability rules (Wells score, Geneva score, blood D-dimer concentration, ECG) were performed in 700 consecutive patients who underwent CTPA due to suspected PE in a single university center between January 2017 and January 2020.

Results: Suspected PE was confirmed by CTPA in 22.7% of considered patients. The independent risk factors for PE diagnosis in CTPA were: history of DVT, diagnosis of DVT on admission, and “PE-likely” score according to simplified Wells scale. Blood D-dimer concentration was associated with the lowest diagnostic accuracy of PE. The combination of simplified Geneva “PE-likely” score with standard or age-adjusted D-dimer cut-offs achieved 100% negative predictive value for PE. In relation to studied PE pre-test probability rules, use YEARS algorithm was associated with the greatest number of CTPAs which could be avoided (9.3%) with the risk < 1% of false-negative categorization.

Conclusions: The combination of simplified Geneva “PE-likely” score with age-adjusted D-dimer cut-offs and YEARS algorithm were more effective than the PERC, original and simplified Wells and Geneva rules in safe exclusion of PE, which might reduce the absolute number of unnecessary CTPA.

Article available in PDF format

View PDF Download PDF file

References

  1. Konstantinides SV, Meyer G, Becattini C, et al. ESC Scientific Document Group. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J. 2020; 41(4): 543–603.
  2. Konstantinides SV, Torbicki A, Agnelli G, et al. Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J. 2014; 35(43): 3033–69, 3069a.
  3. Righini M, Robert-Ebadi H, Righini M, et al. Diagnosis of acute pulmonary embolism. J Thromb Haemost. 2017; 15(7): 1251–1261.
  4. Penaloza A, Soulié C, Moumneh T, et al. Pulmonary embolism rule-out criteria (PERC) rule in European patients with low implicit clinical probability (PERCEPIC): a multicentre, prospective, observational study. Lancet Haematol. 2017; 4(12): e615–e621.
  5. Gorlicki J, Penaloza A, Germeau B, et al. Safety of the Combination of PERC and YEARS Rules in Patients With Low Clinical Probability of Pulmonary Embolism: A Retrospective Analysis of Two Large European Cohorts. Acad Emerg Med. 2019; 26(1): 23–30.
  6. Koziatek CA, Simon E, Horwitz LI, et al. Automated pulmonary embolism risk classification and guideline adherence for computed tomography pulmonary angiography ordering. Acad Emerg Med. 2018; 25(9): 1053–1061.
  7. Freund Y, Cachanado M, Aubry A, et al. PROPER Investigator Group. Effect of the pulmonary embolism rule-out criteria on subsequent thromboembolic events among low-risk emergency department patients: the PROPER randomized clinical trial. JAMA. 2018; 319(6): 559–566.
  8. van der Hulle T, Cheung W, Kooij S, et al. Simplified diagnostic management of suspected pulmonary embolism (the YEARS study): a prospective, multicentre, cohort study. The Lancet. 2017; 390(10091): 289–297.
  9. Ceriani E, Combescure C, Le Gal G, et al. Clinical prediction rules for pulmonary embolism: a systematic review and meta-analysis. J Thromb Haemost. 2010; 8(5): 957–970.
  10. Dronkers CEA, van der Hulle T, Le Gal G, et al. Subcommittee on Predictive and Diagnostic Variables in Thrombotic Disease. Towards a tailored diagnostic standard for future diagnostic studies in pulmonary embolism: communication from the SSC of the ISTH. J Thromb Haemost. 2017; 15(5): 1040–1043.
  11. Pollack CV, Schreiber D, Goldhaber SZ, et al. Clinical characteristics, management, and outcomes of patients diagnosed with acute pulmonary embolism in the emergency department: initial report of EMPEROR (Multicenter Emergency Medicine Pulmonary Embolism in the Real World Registry). J Am Coll Cardiol. 2011; 57(6): 700–706.
  12. Righini M, Van Es J, Den Exter PL, et al. Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism: the ADJUST-PE study. JAMA. 2014; 311(11): 1117–1124.