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Effectiveness of Managing Suspected Pulmonary Embolism Using an Algorithm Combining Clinical Probability, D-Dimer Testing, and Computed Tomography
Writing Group for the Christopher Study Investigators*
JAMA. 2006;295:172-179.
Context Previous studies have evaluated the safety of relatively complex combinations of clinical decision rules and diagnostic tests in patients with suspected pulmonary embolism.
Objective To assess the clinical effectiveness of a simplified algorithm using a dichotomized clinical decision rule, D-dimer testing, and computed tomography (CT) in patients with suspected pulmonary embolism.
Design, Setting, and Patients Prospective cohort study of consecutive patients with clinically suspected acute pulmonary embolism, conducted in 12 centers in the Netherlands from November 2002 through December 2004. The study population of 3306 patients included 82% outpatients and 57% women.
Interventions Patients were categorized as "pulmonary embolism unlikely" or "pulmonary embolism likely" using a dichotomized version of the Wells clinical decision rule. Patients classified as unlikely had D-dimer testing, and pulmonary embolism was considered excluded if the D-dimer test result was normal. All other patients underwent CT, and pulmonary embolism was considered present or excluded based on the results. Anticoagulants were withheld from patients classified as excluded, and all patients were followed up for 3 months.
Main Outcome Measure Symptomatic or fatal venous thromboembolism (VTE) during 3-month follow-up.
Results Pulmonary embolism was classified as unlikely in 2206 patients (66.7%). The combination of pulmonary embolism unlikely and a normal D-dimer test result occurred in 1057 patients (32.0%), of whom 1028 were not treated with anticoagulants; subsequent nonfatal VTE occurred in 5 patients (0.5% [95% confidence interval {CI}, 0.2%-1.1%]). Computed tomography showed pulmonary embolism in 674 patients (20.4%). Computed tomography excluded pulmonary embolism in 1505 patients, of whom 1436 patients were not treated with anticoagulants; in these patients the 3-month incidence of VTE was 1.3% (95% CI, 0.7%-2.0%). Pulmonary embolism was considered a possible cause of death in 7 patients after a negative CT scan (0.5% [95% CI, 0.2%-1.0%]). The algorithm was completed and allowed a management decision in 97.9% of patients.
Conclusions A diagnostic management strategy using a simple clinical decision rule, D-dimer testing, and CT is effective in the evaluation and management of patients with clinically suspected pulmonary embolism. Its use is associated with low risk for subsequent fatal and nonfatal VTE.
*Authors/Christopher Study Writing Group: Arne van Belle, MD, Department of Pulmonary Medicine, Academic Hospital, Maastricht; Harry R. Büller, MD, PhD, Department of Vascular Medicine, Academic Medical Center, Amsterdam; Menno V. Huisman, MD, Department of General Internal Medicine/Endocrinology, Leiden University Medical Center, Leiden; Peter M. Huisman, MD, Department of Radiology, Hilversum Hospital, Hilversum; Karin Kaasjager, MD, Department of Internal Medicine, Rijnstate Hospital, Arnhem; Pieter W. Kamphuisen, MD, Department of General Internal Medicine, Radboud University Medical Center, Nijmegen; Mark H. H. Kramer, MD, Department of Internal Medicine, Meander Medical Center, Amersfoort; Marieke J. H. A. Kruip, MD, Department of Hematology, Erasmus University Medical Center, Rotterdam; Johanna M. Kwakkel-van Erp, MD, Department of Pulmonary Medicine, Rijnstate Hospital, Arnhem; Frank W. G. Leebeek, MD, Department of Hematology, Erasmus University Medical Center, Rotterdam; Mathilde Nijkeuter, MD, Department of General Internal Medicine/Endocrinology, Leiden University Medical Center, Leiden; Martin H. Prins, MD, Department of Clinical Epidemiology, Academic Hospital, Maastricht; Maaike Sohne, MD, Department of Vascular Medicine, Academic Medical Center, Amsterdam; and Lidwine W. Tick, MD, Department of Hematology, Leiden University Medical Center, Leiden; all in the Netherlands.
Christopher Study Investigators: In addition to the Writing Committee, the following institutions and investigators participated in the study: Meander Medical Center, Amersfoort: C. J. M. Halkes, B. Heggelman, M. Nix; Academic Medical Center, Amsterdam: P. Bresser, D. R. Kool, S. S. K. S. Phoa, B. Rekke; Rijnstate Hospital, Arnhem: H. M. H. Grandjean, F. O. H. W. Kesselring, J. J. Mol, E. F. Ullmann; Amphia Hospital, Breda: C. van Guldener, J. Y. Mijnsbergen, M. F. A. M. Sturm; Spaarne Hospital, Haarlem: C. de Swart, P. M. Kuijer, J. G. Schrama, A.v.d. Velde; Hilversum Hospital, Hilversum: M. M. van der Eerden, P. J. H. Janssen, R. Jansen, S. Lobatto; Leiden University Medical Center, Leiden: E. A. Compier, H. C. J. Eikenboom, A. de Roos; Academic Hospital, Maastricht: G. Snoep; Diakonessen Hospital, Meppel: H. de Korte, C. B. Kos, L. Laterveer, W. C. J. van Veldhuizen; Radboud University Medical Center, Nijmegen: S. J. H. Bredie, C. E. van Die, Y. F. Heijdra, J. W. M. Lenders; Erasmus Medical Center, Rotterdam: K-S. G. Jie, A. H. Kars, A. H. van den Meiracker, P. M. T. Pattynama; Medical Center Rijnmond Zuid, Rotterdam: J. M. de Borst, A. van Houten, H. T. Teng.
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