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

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.