Diagnostic outcome management study in patients with clinically suspected recurrent acute pulmonary embolism with a structured algorithm.

Abstract

INTRODUCTION:

The value of diagnostic strategies in patients with clinically suspected recurrent pulmonary embolism (PE) has not been established. The aim was to determine the safety of a simple diagnostic strategy using the Wells clinical decision rule (CDR), quantitative D-dimer testing and computed tomography pulmonary angiography (CTPA) in patients with clinically suspected acute recurrent PE.

MATERIALS AND METHODS:

Multicenter clinical outcome study in 516 consecutive patients with clinically suspected acute recurrent PE without using anticoagulants.

RESULTS:

An unlikely clinical probability (Wells rule 4 points or less) was found in 182 of 516 patients (35%), and the combination of an unlikely CDR-score and normal D-dimer result excluded PE in 88 of 516 patients (17%), without recurrent venous thromboembolism (VTE) during 3month follow-up (0%; 95% CI 0.0-3.4%). CTPA was performed in all other patients and confirmed recurrent PE in 172 patients (overall prevalence of PE 33%) and excluded PE in the remaining 253 patients (49%). During follow-up, seven of these 253 patients returned with recurrent VTE (2.8%; 95% CI 1.2-5.5%), of which in one was fatal (0.4 %; 95 % CI 0.02-1.9%). The diagnostic algorithm was feasible in 98% of patients.

CONCLUSIONS:

A diagnostic algorithm consisting of a clinical decision rule, D-dimer test and CTPA is effective in the management of patients with clinically suspected acute recurrent PE. CTPA provides reasonable safety in excluding acute recurrent PE in patients with a likely clinical probability or an elevated D-dimer test for recurrent PE, with a low risk for fatal PE at follow-up.

• Authors: Inge C M Mos, Renée A Douma, Petra M G Erkens, Marieke J H A Kruip, Marcel M Hovens, Anja A van Houten, Herman M A Hofstee, Judith Kooiman, Frederikus A Klok, Harry R Büller, Pieter W Kamphuisen, Menno V Huisman, Prometheus Study Group
• Journal: Thrombosis research (Thromb Res) Vol. 133 Issue 6 Pg. 1039-44 (Jun 2014) ISSN: 1879-2472 [Electronic] United States
• PMID: 24735976 (Publication Type: Journal Article, Multicenter Study, Research Support, Non-U.S. Gov't)
• Copyright: Copyright © 2014 Elsevier Ltd. All rights reserved.

Chemical References

• Fibrin Fibrinogen Degradation Products
• fibrin fragment D

Topics

• Acute Disease
• Algorithms
• Angiography (methods)
• Female
• Fibrin Fibrinogen Degradation Products (analysis)
• Humans
• Male
• Middle Aged
• Prospective Studies
• Pulmonary Embolism (blood, diagnosis)
• Tomography, X-Ray Computed (methods)
• Treatment Outcome