Excluding Pulmonary Embolism at the Bedside without Diagnostic Imaging: Management of Patients with Suspected Pulmonary Embolism Presenting to the Emergency Department by Using a Simple Clinical Model and d-dimer

@article{Wells2001ExcludingPE,
  title={Excluding Pulmonary Embolism at the Bedside without Diagnostic Imaging: Management of Patients with Suspected Pulmonary Embolism Presenting to the Emergency Department by Using a Simple Clinical Model and d-dimer},
  author={Philip Stephen Wells and David Anderson and Marc Alan Rodger and Ian G. Stiell and Jonathan F. Dreyer and David C Barnes and Melissa A. Forgie and George Kovacs and John Ward and Michael J. Kovacs},
  journal={Annals of Internal Medicine},
  year={2001},
  volume={135},
  pages={98-107}
}
Pulmonary embolism is a relatively common disease, with an estimated annual incidence in the United States of 23 cases diagnosed per 100 000 persons (1). More than 50% of cases are undiagnosed. Untreated pulmonary embolism has a high mortality, although risk for death is reduced significantly with anticoagulation (2). Because the clinical signs and symptoms of pulmonary embolism are not specific, timely diagnostic testing must be done to confirm the diagnosis. Ventilation-perfusion lung… 
Should lung scan be abandoned for pulmonary embolism diagnosis in the age of multislice spiral CT? Yes
TLDR
The diagnosis of pulmonary embolism is a frequent clinical challenge, with approximately 1–3 suspected cases per 1,000 population per year in the western world, and Chest radiography alone is insufficient for most of these diagnoses.
Diagnostic Strategies for Excluding Pulmonary Embolism in Clinical Outcome Studies
TLDR
Whether clinical outcome evaluation properly documented the safety of withholding anticoagulant treatment in patients in whom pulmonary embolism was excluded according to a given diagnostic strategy is investigated.
Noninvasive diagnosis of pulmonary embolism.
TLDR
A diagnostic strategy combining clinical assessment, d-dimer, ultrasonography, and lung scan gave a noninvasive diagnosis in the majority of outpatients with suspected PE and appeared to be safe.
Meta-Analysis: Outcomes in Patients with Suspected Pulmonary Embolism Managed with Computed Tomographic Pulmonary Angiography
TLDR
A systematic review of the literature and meta-analysis of eligible studies to determine the safety and efficacy of withholding systemic anticoagulation after negative results on spiral computed tomographic pulmonary angiography (CTPA).
New Modalities for the Diagnosis of Deep Venous Thrombosis and Pulmonary Embolism
TLDR
Clinical algorithms based on pretest probability and d-dimer testing are promising methods to decrease the need for imaging in the outpatient setting, and may be of great consequence to patients with poor cardiopulmonary reserve.
Performance of the revised Geneva score in patients with a delayed suspicion of pulmonary embolism
TLDR
In patients with inappropriate diagnostic management, symptoms suggestive of pulmonary embolism that could also be ascribed to underlying cardiopulmonary diseases were identified as an important factor in diagnostic failure.
Diagnostic approach to pulmonary embolism and lessons from a busy acute assessment unit in the UK
TLDR
This article reviews the literature concerning the diagnosis of PE, with particular reference to the approach in the acute assessment unit, and describes two learning points from real cases presenting with suspected PE, to highlight how the diagnosis can be missed or made inaccurately.
The diagnostic evaluation of pulmonary embolism.
TLDR
Magnetic resonance imaging and combined computed tomographic pulmonary angiography and venography possess the potential to be used as stand-alone tests for pulmonary embolism but require further evaluation.
Computed tomography pulmonary angiography is overused to diagnose pulmonary embolism in the emergency department of academic community hospital
TLDR
CTPA is overused to diagnose PE in the emergency department and quality improvement projects are needed to encourage physicians to adhere to the current guidelines.
...
...

References

SHOWING 1-10 OF 48 REFERENCES
Use of a Clinical Model for Safe Management of Patients with Suspected Pulmonary Embolism
TLDR
The optimal strategy for investigating patients with suspected pulmonary embolism should combine clinical assessment, ventilation-perfusion scanning, and venous ultrasonography of the lower extremities, and the group developed a useful clinical model by reviewing the literature and coming to a consensus on a scoring system.
Diagnosis of Pulmonary Embolism at a Large Teaching Hospital
TLDR
It is found that in the majority of cases, physicians chose not to further pursue a diagnosis of PE if the V/Q scan was nondiagnostic, suggesting that physician behavior is often at variance with published clinical recommendations and that the implementation of clinical practice guidelines needs to be further examined.
Cost-effective diagnosis of deep vein thrombosis and pulmonary embolism.
TLDR
Novel noninvasive instruments, such as plasma D-dimer measurement, lower limb compression ultrasonography and helical CT scan are important breakthroughs in the management of patients with suspected venous thromboembolism.
Thrombosis in the emergency department: use of a clinical diagnosis model to safely avoid the need for urgent radiological investigation.
TLDR
Using an explicit clinical model, emergency department physicians can accurately classify patients with suspected DVT into high-, moderate, and low-probability groups and a management plan based on probability for DVT that avoids the need for urgent diagnostic imaging is safe and feasible in the emergency department setting.
The clinical course of pulmonary embolism.
TLDR
When properly diagnosed and treated, clinically apparent pulmonary embolism was an uncommon cause of death, and it recurred in only a small minority of patients.
The use of a rapid D-dimer blood test in the diagnostic work-up for pulmonary embolism: a management study.
TLDR
It is safe to withhold anticoagulant therapy in those patients with a non-diagnostic lung scan, a normal SimpliRED D-dimer test result, and without a high clinical probability, which results in a substantial decreased need for ultrasonography and pulmonary angiography.
Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED).
TLDR
Follow-up and angiography together suggest pulmonary embolism occurred among 12% of patients with low-probability scans, and clinical assessment combined with the ventilation/perfusion scan established the diagnosis or exclusion of pulmonary emblism only for a minority of patients--those with clear and concordant clinical and ventilation-perfusions scan findings.
Non-invasive diagnosis of venous thromboembolism in outpatients
...
...