Pulmonary embolism diagnostic approach: Difference between revisions

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Latest revision as of 23:53, 29 July 2020

Editor(s)-In-Chief: C. Michael Gibson, M.S., M.D. [1], The APEX Trial Investigators; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]

Overview

When a patient presents with the cardinal symptoms of pulmonary embolism (PE), such as sudden onset of dyspnea, pleuritic chest pain, tachypnea, and/or tachycardia, the initial step is to stratify the patient into high risk or non-high risk depending on their hemodynamic status. Patients who are suspected to have PE and who are hemodynamically unstable should be administered anticoagulation and should undergo a CT scan or echocardiography if CT scan is unavailable. Among patients who are hemodynamically stable, the pretest probability of PE should be estimated using one of the available scoring systems, the most used of which is the Wells score. Patients who have a low or intermediate pretest probability of PE should undergo D-dimer testing as the initial test, whereas those who have a high pretest probability of PE should undergo a CT scan without a D-dimer test. Patients at intermediate or high pretest probability of PE should be administered anticoagulation therapy before the completion of the diagnostic testing.

Diagnostic Algorithm

A focused initial rapid evaluation should be performed to identify patients suspected of having PE and in need of immediate intervention.^[1]^[2]^[3]

Abbreviations: CT: Computed tomography; IV: Intravenous; IVC: Inferior vena cava; PE: Pulmonary embolism; PERC: PE Rule-Out Criteria; RV: Right ventricle; SC: Subcutaneous; VKA: Vitamin K antagonist

Identify cardinal findings that increase the pretest probability of PE:

❑ Dyspnea
❑ Pleuritic chest pain
❑ Syncope
❑ Tachycardia

❑ Tachypnea

Does the patient who is suspected to have PE have hypotension or shock?

Yes

No

Suspected high-risk PE

Suspected non-high risk PE

Administer anticoagulation
(in case there are no contraindications)
during the diagnostic workup

Is a CT available immediately?

What is the pretest probability of PE?
Assess the pretest probability of PE
by using one of the risk score:
- Wells score
- Geneva score
- PERC

No

Yes

Order echocardiography

Does the patient have RV overload?

Low pretest probability

Intermediate pretest probability

High pretest probability
OR
PE is likely

Administer anticoagulation
(in case there are no contraindications)
during the diagnostic workup

No

Yes

Order CT

Order D-dimer

Positive

Negative

Positive

Negative

Is the patient unstable
OR
no other tests are available?

Is the patient stabilized
AND
CT is now available?

Order CT

PE is excluded

Order CT

Positive

Negative

Positive

Negative

PE is excluded

Consider thrombolytic therapy or embolectomy

Order CT

PE is confirmed

PE is excluded

PE is confirmed

PE is excluded

PE is confirmed

PE is excluded

Positive for PE

Negative for PE

PE is confirmed

PE is excluded

2008 Guidelines on the Diagnosis and Management of Acute Pulmonary Embolism: The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)

ESC 2008 Guidelines for Suspected High-Risk PE (DO NOT EDIT)^[1]

Class I
"1. In high-risk PE, as indicated by the presence of shock or hypotension, emergency CT or bedside echocardiography (depending on availability and clinical circumstances) is recommended for diagnostic purposes. (Level of Evidence: C)"

ESC 2008 Guidelines for Suspected Non-High-Risk PE (DO NOT EDIT)^[1]

Class I
" 1. In non-high-risk PE, basing the diagnostic strategy on clinical probability assessed either implicitly or using a validated prediction rule is recommended. (Level of Evidence: A)"
" 2. Plasma D-dimer measurement is recommended in emergency department patients to reduce the need for unnecessary imaging and irradiation, preferably using a highly sensitive assay. (Level of Evidence: A)"
" 3. The use of validated criteria for diagnosing PE is recommended. Validated criteria according to clinical probability of PE(low, intermediate or high) are detailed below. (Level of Evidence: B)"

Class III
"1. Systematic use of echocardiography for diagnosis in haemodynamically stable, normotensive patients is not recommended.(Level of Evidence: C)"

Class IIa
"1. Pulmonary angiography should be considered when there is discrepancy between clinical evaluation and results of non-invasive imaging tests. (Level of Evidence: C)"

Class IIb
"1. Lower limb compression venous ultrasonography (CUS) in search of DVT may be considered in selected patients with suspected PE to obviate the need for further imaging tests if the result is positive. (Level of Evidence: B)"

ESC 2008 Guidelines for Suspected Non-High-Risk PE (DO NOT EDIT)^[1]

Low Clinical Probability

Class I
"1. Normal D-dimer level using either a highly or moderately sensitive assay excludes PE. (Level of Evidence: A)"
"2. Normal perfusion lung scintigraphy excludes PE. (Level of Evidence: A)"
"3. Negative Multi-slice Detector CT (MDCT) safely excludes PE. (Level of Evidence: A)"
"4. Negative Single-slice Detector CT (SDCT) only excludes PE when combined with negative proximal compression venous ultrasonography.(Level of Evidence: A)"
"5. Compression venous ultrasonography (CUS) showing a proximal DVT confirms PE. (Level of Evidence: B)"
"6. SDCT or MDCT showing a segmental or more proximal thrombus confirms PE. (Level of Evidence: A)"

Class IIa
"1. Non-diagnostic (low or intermediate probability) V/Q scan may exclude PE, (Level of Evidence: B) particularly when combined with negative proximal CUS (Class I,Level of Evidence: A)"
"2. If Compression venous ultrasonography shows only a distal DVT, further testing should be considered to confirm PE. (Level of Evidence: B)"
"3. Further testing should be considered to confirm PE if SDCT or MDCT shows only subsegmental clots. (Level of Evidence: B)"

Class IIb
"1. High-probability V/Q scan may confirm PE but further testing may be considered in selected patients to confirm PE. (Level of Evidence: B)"

Intermediate Clinical Probability

Class I
"1. Normal D-dimer level using a highly sensitive assay excludes PE. (Level of Evidence: A)"
"2. Normal perfusion lung scintigraphy excludes PE. (Level of Evidence: A) "
"3. In case of a non-diagnostic V/Q scan, further testing is recommended to exclude or confirm PE. (Level of Evidence: B)"
"4. Negative MDCT excludes PE. (Level of Evidence: A)"
"5. Negative SDCT only excludes PE when combined with negative proximal CUS.(Level of Evidence: A)"
"6. High-probability ventilation–perfusion lung scintigraphy confirms PE. (Level of Evidence: A)"
"7. Compression venous ultrasonography showing a proximal DVT confirms PE. (Level of Evidence: B)"
"8. SDCT or MDCT showing a segmental or more proximal thrombus confirms PE. (Level of Evidence: A)"

Class IIa
"1. Further testing should be considered if D-dimer level is normal when using a less sensitive assay. (Level of Evidence: B) "
"2. If compression venous ultrasonography shows only a distal DVT, further testing should be considered. (Level of Evidence: B)"

Class IIb
"1. Further testing may be considered in case of subsegmental clots to confirm PE. (Level of Evidence: B)"

High Clinical Probability

Class I
"1. High-probability ventilation–perfusion lung scintigraphy confirms PE. (Level of Evidence: A) "
"2. Compression venous ultrasonography showing a proximal DVT confirms PE. (Level of Evidence: B)"
"3. SDCT or MDCT showing a segmental or more proximal thrombus confirms PE.(Level of Evidence: A)"

Class III
"1. D-dimer measurement is not recommended in high clinical probability patients as a normal result does not safely exclude PE even when using a highly sensitive assay. (Level of Evidence: C)"

Class IIa
"1. In patients with a negative CT, further tests should be considered in selected patients to exclude PE. (Level of Evidence: B) "

Class IIb
"1. If compression venous ultrasonography shows only a distal DVT, further testing should be considered. (Level of Evidence: B)"
"2. Further testing may be considered where there are subsegmental clots, to confirm PE. (Level of Evidence: B)"

References

↑ ^1.0 ^1.1 ^1.2 ^1.3 Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P; et al. (2008). "Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)". Eur Heart J. 29 (18): 2276–315. doi:10.1093/eurheartj/ehn310. PMID 18757870.
↑ Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ; et al. (2011). "Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association". Circulation. 123 (16): 1788–830. doi:10.1161/CIR.0b013e318214914f. PMID 21422387.
↑ Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ; et al. (2012). "Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (2 Suppl): e419S–94S. doi:10.1378/chest.11-2301. PMC 3278049. PMID 22315268.

Template:WH Template:WS

[pmid18757870-1] 1.0 ^1.1 ^1.2 ^1.3 Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P; et al. (2008). "Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)". Eur Heart J. 29 (18): 2276–315. doi:10.1093/eurheartj/ehn310. PMID 18757870.

[pmid21422387-2] Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ; et al. (2011). "Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association". Circulation. 123 (16): 1788–830. doi:10.1161/CIR.0b013e318214914f. PMID 21422387.

[pmid22315268-3] Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ; et al. (2012). "Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (2 Suppl): e419S–94S. doi:10.1378/chest.11-2301. PMC 3278049. PMID 22315268.

[1]

[2]

[3]

@@ Line 1: / Line 1: @@
+__NOTOC__
+{| class="infobox" style="float:right;"
+|-
+| [[File:Siren.gif|30px|link=Pulmonary embolism resident survival guide]]|| <br> || <br>
+| [[Pulmonary embolism resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
+|}
 {{Pulmonary embolism}}
+'''Editor(s)-In-Chief:''' [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com], {{ATI}}; {{AE}} {{Rim}}
-{{CMG}}
-'''Associate Editors-in-Chief:''' [[User:Ujjwal Rastogi|Ujjwal Rastogi, MBBS]] [mailto:urastogi@perfuse.org]
 ==Overview==
-Signs and symptoms of pulmonary embolism are nonspecific; therefore, patients presenting with:
+When a patient presents with the cardinal [[symptoms]] of pulmonary embolism (PE), such as sudden [[onset]] of [[dyspnea]], [[pleuritic chest pain]], [[tachypnea]], and/or [[tachycardia]], the initial step is to stratify the patient into high risk or non-high risk depending on their [[hemodynamic]] status.  Patients who are suspected to have [[PE]] and who are [[hemodynamically]] unstable should be administered [[anticoagulation]] and should undergo a [[CT]] scan or [[echocardiography]] if [[CT scan]] is unavailable.   Among patients who are [[hemodynamically]] stable, the pretest probability of [[PE]] should be estimated using one of the available scoring systems, the most used of which is the [[Wells score for PE|Wells score]].  Patients who have a low or intermediate pretest probability of PE should undergo [[D-dimer|D-dimer testing]] as the initial test, whereas those who have a high pretest probability of PE should undergo a [[CT scan]] without a [[D-dimer test]].  Patients at intermediate or high pretest probability of PE should be administered [[anticoagulation therapy]] before the completion of the diagnostic testing.
-*Unexplained [[dyspnea]]
-*[[Tachypnea]]
+==Diagnostic Algorithm==
-*[[Chest pain]]
+A focused initial rapid evaluation should be performed to identify patients suspected of having PE and in need of immediate intervention.<ref name="pmid18757870">{{cite journal| author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P et al.| title=Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 18 | pages= 2276-315 | pmid=18757870 | doi=10.1093/eurheartj/ehn310 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757870  }} </ref><ref name="pmid21422387">{{cite journal| author=Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ et al.| title=Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. | journal=Circulation | year= 2011 | volume= 123 | issue= 16 | pages= 1788-830 | pmid=21422387 | doi=10.1161/CIR.0b013e318214914f | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21422387  }} </ref><ref name="pmid22315268">{{cite journal| author=Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ et al.| title=Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e419S-94S | pmid=22315268 | doi=10.1378/chest.11-2301 | pmc=PMC3278049 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315268  }} </ref>
-*Risk factors for pulmonary embolism
-—should undergo diagnostic tests until the diagnosis is confirmed or eliminated or an alternative diagnosis is made.
-== CT equipped hospitals ==
+<span style="font-size:85%"> '''Abbreviations:''' '''CT:''' [[Computed tomography]]; '''IV:''' [[Intravenous]]; '''IVC:''' [[Inferior vena cava]]; '''PE:''' [[Pulmonary embolism]]; '''PERC:''' [[PERC|PE Rule-Out Criteria]]; '''RV:''' [[Right ventricle]]; '''SC:''' [[Subcutaneous]]; '''VKA:''' [[Vitamin K antagonist]] </span>
-In hospitals having experience in performing and interpreting CT Pulmonary angiography, following flowchart approach can be adopted.
-{{familytree/start |summary=PE diagnosis Algorithm.}}
+{{familytree/start}}
-{{familytree | | | | | | | | GMa | GMa='''Determine chances of PE'''}}
+{{familytree | | | | | | | | | | | | | | | | AA0 | | | | AA0=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''Identify cardinal findings that increase the pretest probability of PE:'''
-{{familytree | | | | |,|-|-|-|^|-|-|-|-|.| | | }}
+❑ [[Dyspnea]] <br>
-{{familytree | | |JOE| | | | | | | |SIS| | | JOE='''Low chance'''|SIS='''High chance'''}}
+❑ [[Pleuritic chest pain]] <br>
-{{familytree | | | |!| | | | | | | | | |!| }}
+❑ [[Syncope]] <br>
-{{familytree | | |MOM| | | | | | | | |!| |MOM='''[[D-dimer]]'''}}
+❑ [[Tachycardia]] <br>
-{{familytree | |,|-|^|.| | | | | | | | |!| }}
+❑ [[Tachypnea]]</div>}}
-{{familytree |GPa| |JOE|~|~|~|~|~|MOM|GPa='''<500 ng/ml'''|JOE='''>500 ng/ml'''|MOM='''[[Pulmonary embolism other imaging findings#Angiography|CT Pulmonary angiography]]'''}}
+{{familytree | | | | | | | | | | | | | | | | |!| | | | | }}
-{{familytree | |!| | | | | | | | | |,|-|^|.| }}
+{{familytree | | | | | | | | | | | | | | | | A00 | | | | | A00= '''Does the patient who is suspected to have PE have [[hypotension]] or [[shock]]?'''}}
-{{familytree |MOM| | | | | | |SIS| | |GMa|MOM='''PE excluded'''|SIS=Negative|GMa=Positive}}
+{{familytree | | | | | | | |,|-|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|-|.| }}
-{{familytree | | | | | | | | | | |!| | | | |!| }}
+{{familytree | | | | | | | A01 | | | | | | | | | | | | | | | | | A02 |  A01= Yes| A02= No}}
-{{familytree | | | | | | | | | |SIS| | |GMa|SIS='''PE excluded'''|GMa='''PE confirmed'''}}
+{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | |!| }}
+{{familytree | | | | | | | A02 | | | | | | | | | | | | | | | | | A03 |  A02= '''Suspected high-risk PE'''| A03= '''Suspected non-high risk PE'''}}
+{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | |!| }}
+{{familytree | | | | | | | A04 | | | | | | | | | | | | | | | | | |!| A04= ''Administer [[anticoagulation]]'' <br>''(in case there are no contraindications)''<br>''during the diagnostic workup''}}
+{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | |!| }}
+{{familytree | | | | | | | B01 | | | | | | | | | | | | | | | | | B02| B01= '''Is a [[CT]] available immediately?'''| B02= '''What is the pretest probability of PE?''' <br> Assess the pretest probability of PE<br> by using one of the risk score:<br> - [[Wells score]] <br> - [[Geneva score]] <br> - [[PERC]]}}
+{{familytree | | | |,|-|-|-|^|-|-|-|-|-|-|-|.| | | | | | |,|-|v|-|^|-|-|.| | }}
+{{familytree | | | C01 | | | | | | | | | | C02 | | | | | |!| |!| | | | |!| | C01= No| C02= Yes}}
+{{familytree | | | |!| | | | | | | | | | | |!| | | | | | |!| |!| | | | |!| | }}
+{{familytree | | | D01 | | | | | | | | | | |!| | | | | | |!| |!| | | | |!| | D01= '''Order [[echocardiography]]'''}}
+{{familytree | | | |!| | | | | | | | | | | |!| | | | | | |!| |!| | | | |!| | }}
+{{familytree | | | E01 | | | | | | | | | | |!| | | | | E02 | | E03 | | E04 |  E01= '''Does the patient have [[RV]] overload?'''| E02= '''Low pretest probability''' |E03= '''Intermediate pretest probability'''| E04= '''High pretest probability''' <br>OR<br> '''PE is likely'''}}
+{{familytree | | | |!| | | | | | | | | | | |!| | | | | | |!| |!| | | | |!| }}
+{{familytree | | | |!| | | | | | | | | | | |!| | | | | | |!| | N01 | | N02 | N01= ''Administer [[anticoagulation]]'' <br>''(in case there are no contraindications)''<br>''during the diagnostic workup''|N02= ''Administer [[anticoagulation]]'' <br>''(in case there are no contraindications)''<br>''during the diagnostic workup''}}
+{{familytree | |,|-|^|-|-|-|.| | | | | | | |!| | | | | | |!| |!| | | | |!| | }}
+{{familytree | F01 | | | | F02 | | | | | | F03 | | | | | | F04 | | | | |!| F01= No| F02= Yes| F03= '''Order [[CT]]'''| F04= '''Order [[D-dimer]]'''}}
+{{familytree | |!| | | | | |!| | | | | |,|-|^|-|.| | | |,|-|^|-|.| | | |!| }}
+{{familytree | |!| | | | | |!| | | | | G02 | | G03 | | G04 | | G05 | | |!| G01= | G02= Positive| G03= Negative| G04= Positive| G05= Negative}}
+{{familytree | |!| | | |,|-|^|-|.| | | |!| | | |!| | | |!| | | |!| | | |!| }}
+{{familytree | |!| | | H01 | | H02 | | |!| | | |!| | | H03 | | H04 | | H05 | | | H01= Is the patient unstable <br> OR<br> no other tests are available?| H02=Is the patient stabilized <br> AND <br> CT is now available?| H03= '''Order CT'''| H04= PE is excluded| H05= '''Order [[CT]]'''}}
+{{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | |)|-|-|-|.| | | |)|-|-|-|.| | }}
+{{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | L01 | | L02 | | L03 | | L04 | L01= Positive| L02= Negative| L03= Positive| L04= Negative}}
+{{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | }}
+{{familytree | I01 | | I02 | | I03 | | I04 | | I05 | | I06 | | I07 | | I08 | | I09 | I01= PE is excluded| I02= Consider [[thrombolytic therapy]] or [[embolectomy]]| I03= Order CT| I04= PE is confirmed| I05=PE is excluded| I06= PE is confirmed| I07= PE is excluded| I08= PE is confirmed| I09= PE is excluded}}
+{{familytree | | | | | | | |,|-|^|-|.| | | | }}
+{{familytree | | | | | | | J01 | | J02 | | | J01= Positive for PE| J02= Negative for PE}}
+{{familytree | | | | | | | |!| | | |!| | | | }}
+{{familytree | | | | | | | K01 | | K02 | | | K01= PE is confirmed| K02= PE is excluded}}
 {{familytree/end}}
-==CT Non-equipped hospitals==
+==2008 Guidelines on the Diagnosis and Management of Acute Pulmonary Embolism: The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)==
-Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) Study proposed the following, for hospitals who do not have sufficient resources to perform or interpret CT Pulmonary angiography.
+===ESC 2008 Guidelines for Suspected High-Risk PE (DO NOT EDIT)<ref name="pmid18757870">{{cite journal |author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P, Bengel F, Brady AJ, Ferreira D, Janssens U, Klepetko W, Mayer E, Remy-Jardin M, Bassand JP |title=Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC) |journal=Eur. Heart J. |volume=29|issue=18 |pages=2276–315 |year=2008 |month=September |pmid=18757870 |doi=10.1093/eurheartj/ehn310|url=http://eurheartj.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=18757870 |accessdate=2011-12-07}}</ref>===
-Wells criteria are used to assess the clinical probability of PE and its graded as Low, Intermediate or High. later a ventilation-perfusion scan (V/Q) is performed, and based on the result of the scan PE is diagnosed.
+{|class="wikitable"
+|-
+| colspan="1" style="text-align:center; background:LightGreen"|[[European society of cardiology#Classes of Recommendations|Class I]]
+|-
+| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' In high-risk PE, as indicated by the presence of [[shock]] or [[hypotension]], emergency CT or bedside echocardiography (depending on availability and clinical circumstances) is recommended for diagnostic purposes. ''([[European society of cardiology#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
+|}
-'''The following table summarizes the possible outcome of V/Q scan:'''
+===ESC 2008 Guidelines for Suspected Non-High-Risk PE (DO NOT EDIT)<ref name="pmid18757870">{{cite journal |author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P, Bengel F, Brady AJ, Ferreira D, Janssens U, Klepetko W, Mayer E, Remy-Jardin M, Bassand JP |title=Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC) |journal=Eur. Heart J. |volume=29|issue=18 |pages=2276–315 |year=2008 |month=September |pmid=18757870 |doi=10.1093/eurheartj/ehn310|url=http://eurheartj.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=18757870 |accessdate=2011-12-07}}</ref>===
-{| border="1"
+{|class="wikitable"
-|+
-! [[Pulmonary embolism ventilation/perfusion scan|V/Q Scan]] !! [[Pulmonary embolism diagnosis#Wells score|Clinical Probability]] !! Diagnosis
 |-
-| Normal
+| colspan="1" style="text-align:center; background:LightGreen"|[[European society of cardiology#Classes of Recommendations|Class I]]
-| any probability
-| PE excluded
 |-
-| Low probability scan
+| bgcolor="LightGreen"|<nowiki>"</nowiki> '''1.''' In non-high-risk PE, basing the diagnostic strategy on clinical probability assessed either implicitly or using a validated prediction rule is recommended. ''([[European society of cardiology#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
-| Low
-| PE excluded
 |-
-| High probability scan
+| bgcolor="LightGreen"|<nowiki>"</nowiki> '''2.''' Plasma [[D-dimer]] measurement is recommended in emergency department patients to reduce the need for unnecessary imaging and irradiation, preferably using a highly sensitive assay. ''([[European society of cardiology#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
-| High
-| PE confirmed
 |-
-| Variable result/Non diagnostic
+| bgcolor="LightGreen"|<nowiki>"</nowiki> '''3.''' The use of validated criteria for diagnosing PE is recommended. Validated criteria according to clinical probability of PE(low, intermediate or high) are detailed below. ''([[European society of cardiology#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
-| Variable
-| Serial [[Deep vein thrombosis ultrasound|lower extremity USG]] or [[Pulmonary embolism other imaging findings#Angiography|Pulmonary angiography]]
 |}
+{|class="wikitable"
+|-
+|colspan="1" style="text-align:center; background:LightCoral"|[[European society of cardiology#Classes of Recommendations|Class III]]
+|-
+|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' Systematic use of [[echocardiography]] for diagnosis in haemodynamically stable, normotensive patients is not recommended.''([[European society of cardiology#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
+|}
-==Low risk outpatient population==
+{|class="wikitable"
-In populations where the PE prevalence is low, the following eight factors constitute the PE rule-out criteria ('''PERC'''):
+|-
-*Age less than 50 years
+| colspan="1" style="text-align:center; background:LemonChiffon"|[[European society of cardiology#Classes of Recommendations|Class IIa]]
-*Heart rate less than 100 bpm
+|-
-*Oxyhemoglobin saturation ≥95 percent
+|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' [[Pulmonary angiography]] should be considered when there is discrepancy between clinical evaluation and results of non-invasive imaging tests. ''([[European society of cardiology#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
-*No hemoptysis
+|}
-*No estrogen use
-*No prior DVT or PE
-*No unilateral leg swelling
-*No surgery or trauma requiring hospitalization within the past four weeks.
-This approach was tested in a multicenter study involving 8138 outpatients with suspected PE.<ref name="pmid18318689">{{cite journal |author=Kline JA, Courtney DM, Kabrhel C, Moore CL, Smithline HA, Plewa MC, Richman PB, O'Neil BJ, Nordenholz K |title=Prospective multicenter evaluation of the pulmonary embolism rule-out criteria |journal=J. Thromb. Haemost. |volume=6 |issue=5 |pages=772–80 |year=2008 |month=May |pmid=18318689 |doi=10.1111/j.1538-7836.2008.02944.x |url=http://dx.doi.org/10.1111/j.1538-7836.2008.02944.x |accessdate=2011-12-19}}</ref>
+{|class="wikitable"
+|-
+| colspan="1" style="text-align:center; background:LemonChiffon"|[[European society of cardiology#Classes of Recommendations|Class IIb]]
+|-
+|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Lower limb compression venous ultrasonography (CUS) in search of DVT may be considered in selected patients with suspected PE to obviate the need for further imaging tests if the result is positive. ''([[European society of cardiology#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
+|}
+===ESC 2008 Guidelines for Suspected Non-High-Risk PE (DO NOT EDIT)<ref name="pmid18757870">{{cite journal |author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P, Bengel F, Brady AJ, Ferreira D, Janssens U, Klepetko W, Mayer E, Remy-Jardin M, Bassand JP |title=Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC) |journal=Eur. Heart J. |volume=29|issue=18 |pages=2276–315 |year=2008 |month=September |pmid=18757870 |doi=10.1093/eurheartj/ehn310|url=http://eurheartj.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=18757870 |accessdate=2011-12-07}}</ref>===
+====Low Clinical Probability====
+{|class="wikitable"
+|-
+| colspan="1" style="text-align:center; background:LightGreen"|[[European society of cardiology#Classes of Recommendations|Class I]]
+|-
+| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Normal D-dimer level using either a highly or moderately sensitive assay excludes PE. ''([[European society of cardiology#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
+|-
+| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Normal perfusion lung [[scintigraphy]] excludes PE. ''([[European society of cardiology#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
+|-
+| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' Negative Multi-slice Detector CT (MDCT) safely excludes PE. ''([[European society of cardiology#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
+|-
+| bgcolor="LightGreen"|<nowiki>"</nowiki>'''4.''' Negative Single-slice Detector CT (SDCT) only excludes PE when combined with negative proximal compression venous ultrasonography.''([[European society of cardiology#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
+|-
+| bgcolor="LightGreen"|<nowiki>"</nowiki>'''5.''' Compression venous ultrasonography (CUS) showing a proximal DVT confirms PE. ''([[European society of cardiology#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
+|-
+| bgcolor="LightGreen"|<nowiki>"</nowiki>'''6.''' SDCT or MDCT showing a segmental or more proximal thrombus confirms PE. ''([[European society of cardiology#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
+|}
+{|class="wikitable"
+|-
+| colspan="1" style="text-align:center; background:LemonChiffon"|[[European society of cardiology#Classes of Recommendations|Class IIa]]
+|-
+|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Non-diagnostic (low or intermediate probability) V/Q scan may exclude PE, ''([[European society of cardiology#Level of Evidence|Level of Evidence: B]])'' particularly when combined with negative proximal CUS ''([[European society of cardiology#Classes of Recommendations|Class I]],[[European society of cardiology#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
+|-
+|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' If Compression venous ultrasonography shows only a distal DVT, further testing should be considered to confirm PE. ''([[European society of cardiology#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
+|-
+|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' Further testing should be considered to confirm PE if SDCT or MDCT shows only subsegmental clots. ''([[European society of cardiology#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
+|}
+{|class="wikitable"
+|-
+| colspan="1" style="text-align:center; background:LemonChiffon"|[[European society of cardiology#Classes of Recommendations|Class IIb]]
+|-
+|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' High-probability V/Q scan may confirm PE but further testing may be considered in selected patients to confirm PE. ''([[European society of cardiology#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
+|}
+====Intermediate Clinical Probability====
+{|class="wikitable"
+|-
+| colspan="1" style="text-align:center; background:LightGreen"|[[European society of cardiology#Classes of Recommendations|Class I]]
+|-
+| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Normal D-dimer level using a highly sensitive assay excludes PE. ''([[European society of cardiology#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
+|-
+| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Normal perfusion lung scintigraphy excludes PE. ''([[European society of cardiology#Level of Evidence|Level of Evidence: A]])'' <nowiki>"</nowiki>
+|-
+| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' In case of a non-diagnostic V/Q scan, further testing is recommended to exclude or confirm PE. ''([[European society of cardiology#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
+|-
+| bgcolor="LightGreen"|<nowiki>"</nowiki>'''4.''' Negative MDCT excludes PE. ''([[European society of cardiology#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
+|-
+| bgcolor="LightGreen"|<nowiki>"</nowiki>'''5.''' Negative SDCT only excludes PE when combined with negative proximal CUS.''([[European society of cardiology#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
+|-
+| bgcolor="LightGreen"|<nowiki>"</nowiki>'''6.''' High-probability ventilation–perfusion lung scintigraphy confirms PE. ''([[European society of cardiology#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
+|-
+| bgcolor="LightGreen"|<nowiki>"</nowiki>'''7.''' Compression venous ultrasonography showing a proximal DVT confirms PE. ''([[European society of cardiology#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
+|-
+| bgcolor="LightGreen"|<nowiki>"</nowiki>'''8.''' SDCT or MDCT showing a segmental or more proximal thrombus confirms PE. ''([[European society of cardiology#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
+|}
+{|class="wikitable"
+|-
+| colspan="1" style="text-align:center; background:LemonChiffon"|[[European society of cardiology#Classes of Recommendations|Class IIa]]
+|-
+|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Further testing should be considered if D-dimer level is normal when using a less sensitive assay. ''([[European society of cardiology#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
+|-
+|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' If compression venous ultrasonography shows only a distal DVT, further testing should be considered. ''([[European society of cardiology#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
+|}
+{|class="wikitable"
+|-
+| colspan="1" style="text-align:center; background:LemonChiffon"|[[European society of cardiology#Classes of Recommendations|Class IIb]]
+|-
+|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Further testing may be considered in case of subsegmental clots to confirm PE. ''([[European society of cardiology#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
+|}
+====High Clinical Probability====
+{|class="wikitable"
+|-
+| colspan="1" style="text-align:center; background:LightGreen"|[[European society of cardiology#Classes of Recommendations|Class I]]
+|-
+| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' High-probability ventilation–perfusion lung scintigraphy confirms PE. ''([[European society of cardiology#Level of Evidence|Level of Evidence: A]])'' <nowiki>"</nowiki>
+|-
+| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Compression venous ultrasonography showing a proximal DVT confirms PE. ''([[European society of cardiology#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
+|-
+| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' SDCT or MDCT showing a segmental or more proximal thrombus confirms PE.''([[European society of cardiology#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
+|}
+{|class="wikitable"
+|-
+|colspan="1" style="text-align:center; background:LightCoral"|[[European society of cardiology#Classes of Recommendations|Class III]]
+|-
+|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' D-dimer measurement is not recommended in high clinical probability patients as a normal result does not safely exclude PE even when using a highly sensitive assay. ''([[European society of cardiology#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
+|}
+{|class="wikitable"
+|-
+| colspan="1" style="text-align:center; background:LemonChiffon"|[[European society of cardiology#Classes of Recommendations|Class IIa]]
+|-
+|bgcolor="LemonChiffon"|
+<nowiki>"</nowiki>'''1.''' In patients with a negative CT, further tests should be considered in selected patients to exclude PE. ''([[European society of cardiology#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
+|}
+{|class="wikitable"
+|-
+| colspan="1" style="text-align:center; background:LemonChiffon"|[[European society of cardiology#Classes of Recommendations|Class IIb]]
+|-
+|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' If compression venous ultrasonography shows only a distal DVT, further testing should be considered. ''([[European society of cardiology#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
+|-
+|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' Further testing may be considered where there are subsegmental clots, to confirm PE. ''([[European society of cardiology#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
+|}
 ==References==
-{{reflist|2}}
+{{Reflist|2}}
+{{WH}}
+{{WS}}
 [[Category:Hematology]]
@@ Line 77: / Line 232: @@
 [[Category:Cardiology]]
 [[Category:Emergency medicine]]
+[[Category:Intensive care medicine]]
-{{WH}}
-{{WS}}

Pulmonary embolism diagnostic approach: Difference between revisions

Latest revision as of 23:53, 29 July 2020

Overview

Diagnostic Algorithm

2008 Guidelines on the Diagnosis and Management of Acute Pulmonary Embolism: The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)

ESC 2008 Guidelines for Suspected High-Risk PE (DO NOT EDIT)[1]

ESC 2008 Guidelines for Suspected Non-High-Risk PE (DO NOT EDIT)[1]

ESC 2008 Guidelines for Suspected Non-High-Risk PE (DO NOT EDIT)[1]

Low Clinical Probability

Intermediate Clinical Probability

High Clinical Probability

References

Navigation menu

ESC 2008 Guidelines for Suspected High-Risk PE (DO NOT EDIT)^[1]

ESC 2008 Guidelines for Suspected Non-High-Risk PE (DO NOT EDIT)^[1]

ESC 2008 Guidelines for Suspected Non-High-Risk PE (DO NOT EDIT)^[1]