Abstract
Objectives. We conducted a study to answer 3 questions: (1) is CT pulmonary angiography (CTPA) overutilized in suspected pulmonary embolism (PE)? (2) What alternative diagnoses are provided by CTPA? (3) Can CTPA be used to evaluate right ventricular dilatation (RVD)? Methods. We retrospectively reviewed the clinical information of 231 consecutive emergency department patients who underwent CTPA for suspected PE over a one-year period. Results. The mean age of our patients was 53 years, and 58.4% were women. The prevalence of PE was 20.7%. Among the 136 patients with low clinical probability of PE, a d-dimer test was done in 54.4%, and it was normal in 24.3%; none of these patients had PE. The most common alternative findings on CTPA were emphysema (7.6%), pneumonia (7%), atelectasis (5.5%), bronchiectasis (3.8%), and congestive heart failure (3.3%). The sensitivity and negative predictive value of CTPA for (RVD) was 92% and 80%, respectively. Conclusions. PE could have been excluded without CTPA in ~1 out of 4 patients with low clinical probability of PE, if a formal assessment of probability and d-dimer test had been done. In patients without PE, CTPA did not provide an alternative diagnosis in 65%. In patients with PE, CTPA showed the potential to evaluate RVD.
Highlights
The paradox in the diagnosis of pulmonary embolism (PE) is that it tends to be both underdiagnosed and overinvestigated
We retrospectively reviewed the clinical information of 231 consecutive emergency department (ED) patients who were suspected of PE and underwent a CT pulmonary angiography (CTPA) during the one-year period, January 2005
It shows that in a major urban ED like ours, where no clinical practice guideline for evaluation of PE was in place, if a clinical prediction model is used to assign a probability to ED patients suspected of PE and a d-dimer sample is sent in all the patients with a low clinical probability of PE, a CTPA can be avoided in approximately one-quarter of such patients
Summary
The paradox in the diagnosis of pulmonary embolism (PE) is that it tends to be both underdiagnosed and overinvestigated. The widespread round-theclock availability, excellent accuracy [9, 10] of CT pulmonary angiography (CTPA), and ability to provide an alternative diagnosis [11, 12] may further lower the threshold for performing this imaging study and result in its overuse. The impact of such evidence-based strategies on actual clinical practice is not known. In this era of evidence-based decision making and cost-effective utilization of resources, it is imperative to diagnose and risk-stratify emergency department (ED) patients with pulmonary embolism in a more objective manner. We sought to answer these three questions: (1) is CTPA overutilized? (2) What alternative or incidental diagnoses are provided by CTPA? (3) Can CTPA be used to evaluate right ventricular dilatation (RVD)?
Sign-in/Register to view highlights & summary Sign-in/Register to access full text options 
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a call
