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A Systematic Review

Rene Quiroz, MD, MPH; Nils Kucher, MD; Kelly H. Zou, PhD; Florian Kipfmueller, BS; Philip Costello, MD; Samuel Z. Goldhaber, MD; U. Joseph Schoepf, MD

JAMA. 2005;293:2012-2017.

Context  The clinical validity of using computed tomography (CT) to diagnose peripheral pulmonary embolism is uncertain. Insufficient sensitivity for peripheral pulmonary embolism is considered the principal limitation of CT.

Objective  To review studies that used a CT-based approach to rule out a diagnosis of pulmonary embolism.

Data Sources  The medical literature databases of PubMed, MEDLINE, EMBASE, CRISP, metaRegister of Controlled Trials, and Cochrane were searched for articles published in the English language from January 1990 to May 2004.

Study Selection  We included studies that used contrast-enhanced chest CT to rule out the diagnosis of acute pulmonary embolism, had a minimum follow-up of 3 months, and had study populations of more than 30 patients.

Data Extraction  Two reviewers independently abstracted patient demographics, frequency of venous thromboembolic events (VTEs), CT modality (single-slice CT, multidetector-row CT, or electron-beam CT), false-negative results, and deaths attributable to pulmonary embolism. To calculate the overall negative likelihood ratio (NLR) of a VTE after a negative or inconclusive chest CT scan for pulmonary embolism, we included VTEs that were objectively confirmed by an additional imaging test despite a negative or inconclusive CT scan and objectively confirmed VTEs that occurred during clinical follow-up of at least 3 months.

Data Synthesis  Fifteen studies met the inclusion criteria and contained a total of 3500 patients who were evaluated from October 1994 through April 2002. The overall NLR of a VTE after a negative chest CT scan for pulmonary embolism was 0.07 (95% confidence interval [CI], 0.05-0.11); and the negative predictive value (NPV) was 99.1% (95% CI, 98.7%-99.5%). The NLR of a VTE after a negative single-slice spiral CT scan for pulmonary embolism was 0.08 (95% CI, 0.05-0.13); and after a negative multidetector-row CT scan, 0.15 (95% CI, 0.05-0.43). There was no difference in risk of VTEs based on CT modality used (relative risk, 1.66; 95% CI, 0.47-5.94; P = .50). The overall NLR of mortality attributable to pulmonary embolism was 0.01 (95% CI, 0.01-0.02) and the overall NPV was 99.4% (95% CI, 98.7%-99.9%).

Conclusion  The clinical validity of using a CT scan to rule out pulmonary embolism is similar to that reported for conventional pulmonary angiography.

Author Affiliations: Department of Radiology (Drs Quiroz, Zou, Costello, and Schoepf and Mr Kipfmueller) and Cardiovascular Division, Department of Medicine (Drs Quiroz, Kucher, and Goldhaber), Brigham and Women's Hospital, Boston, Mass; Department of Health Care Policy, Harvard Medical School, Boston, Mass (Dr Zou); and Department of Radiology, Medical University of South Carolina, Charleston (Drs Costello and Schoepf).

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