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    Ruling out Pulmonary Embolism in Patients with High Pretest Probability

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    Author
    Akhter, Murtaza
    Kline, Jeffrey
    Bhattarai, Bikash
    Courtney, Mark
    Kabrhel, Christopher
    Affiliation
    Univ Arizona, Coll Med Phoenix, Maricopa Integrated Hlth Syst, Dept Emergency Med
    Univ Arizona, Coll Med Phoenix, Maricopa Integrated Hlth Syst, Dept Med Adm
    Issue Date
    2018-05
    
    Metadata
    Show full item record
    Publisher
    WESTJEM
    Citation
    Akhter, M., Kline, J., Bhattarai, B., Courtney, M., & Kabrhel, C. (2018). Ruling out Pulmonary Embolism in Patients with High Pretest Probability. Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health, 19(3). http://dx.doi.org/10.5811/westjem.2017.10.36219
    Journal
    WESTERN JOURNAL OF EMERGENCY MEDICINE
    Rights
    Copyright: © 2018 Akhter et al. This is an open access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) License.
    Collection Information
    This item from the UA Faculty Publications collection is made available by the University of Arizona with support from the University of Arizona Libraries. If you have questions, please contact us at repository@u.library.arizona.edu.
    Abstract
    Introduction: The American College of Emergency Physicians guidelines recommend more aggressive workup beyond imaging alone in patients with a high pretest probability (PTP) of pulmonary embolism (PE). However, the ability of multiple tests to safely rule out PE in high PTP patients is not known. We sought to measure the ability of negative computed tomography pulmonary angiography (CTPA) along with negative D-dimer to rule out PE in these high-risk patients. Methods: We analyzed data from a previous prospective observational study conducted in 12 emergency departments (ED). Wells score criteria were entered by providers before final PE testing. PE was diagnosed by imaging on the index ED visit, or within 45 days, demonstrating either PE or deep vein thrombosis (DVT), or if the patient died of PE during the 45-day, follow-up period. Testing threshold was set at 1.8%. Results: A total of 7,940 patients were enrolled and tested for PE, and 257 had high PTP (Wells > 6). Sixteen of these high-risk patients had negative CTPA and negative D-dimer, of whom two were positive for PE (12.5% [95% confidence interval {2.2%-40.0%}]). One of these patients had a DVT on CT venogram and the other was diagnosed at follow-up. Conclusion: Our analysis suggests that in patients with high PTP of PE, neither negative CTPA by itself nor a negative CTPA plus a negative D-dimer are sufficient to rule out PE. More aggressive workup strategies may be required for these patients.
    Note
    Open access journal.
    ISSN
    19369018
    PubMed ID
    29760845
    DOI
    10.5811/westjem.2017.10.36219
    Version
    Final published version
    Sponsors
    Emergency Medicine Foundation; National Institutes of Health; Diagnostica Stago; Siemens Healthcare; Janssen; Roche; Pfizer; Massachusetts General Hospital
    Additional Links
    https://escholarship.org/uc/item/74h4h8qb
    ae974a485f413a2113503eed53cd6c53
    10.5811/westjem.2017.10.36219
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