 |
|
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.
RELATED LETTERS
An Algorithm for Managing Suspected Pulmonary Embolism
Hisato Takagi and Takuya Umemoto
JAMA. 2006;295(22):2603-2604.
EXTRACT
| FULL TEXT
An Algorithm for Managing Suspected Pulmonary Embolism—Reply
Mathilde Nijkeuter, M. H. Prins, H. R. Büller, Menno V. Huisman, and for the Christopher Study Investigators
JAMA. 2006;295(22):2604.
EXTRACT
| FULL TEXT
RELATED ARTICLES
Does This Patient Have Deep Vein Thrombosis?
Philip S. Wells, Carolyn Owen, Steve Doucette, Dean Fergusson, and Huyen Tran
JAMA. 2006;295(2):199-207.
ABSTRACT
| FULL TEXT
Diagnosing Pulmonary Embolism With Improved Certainty and Simplicity
Russell D. Hull
JAMA. 2006;295(2):213-215.
EXTRACT
| FULL TEXT
Pulmonary Embolism
Sharon Parmet, Cassio Lynm, and Richard M. Glass
JAMA. 2006;295(2):240.
EXTRACT
| FULL TEXT
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
|
Pulmonary Embolism in Heart Failure
Piazza and Goldhaber
Circulation 2008;118:1598-1601.
FULL TEXT
The Importance of Clinical Probability Assessment in Interpreting a Normal d-Dimer in Patients With Suspected Pulmonary Embolism
Gibson et al.
Chest 2008;134:789-793.
ABSTRACT
| FULL TEXT
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)
Authors/Task Force Members et al.
Eur Heart J 2008;29:2276-2315.
FULL TEXT
Simple and Accurate Prediction of the Clinical Probability of Pulmonary Embolism
Miniati et al.
Am. J. Respir. Crit. Care Med. 2008;178:290-294.
ABSTRACT
| FULL TEXT
When Is Diagnostic Testing Inappropriate or Irrational? Acceptable Regret Approach
Hozo and Djulbegovic
Med Decis Making 2008;28:540-553.
ABSTRACT
Acute pulmonary embolism revisited: Thromboembolic venous disease
Konstantinides
Heart 2008;94:795-802.
FULL TEXT
Pulmonary Embolism Outcome: A Prospective Evaluation of CT Pulmonary Angiographic Clot Burden Score and ECG Score
Subramaniam et al.
Am. J. Roentgenol. 2008;190:1599-1604.
ABSTRACT
| FULL TEXT
Acute Pulmonary Embolism
Tapson
NEJM 2008;358:1037-1052.
FULL TEXT
Acute Pulmonary Embolism: Sensitivity and Specificity of Ventilation-Perfusion Scintigraphy in PIOPED II Study
Sostman et al.
Radiology 2008;246:941-946.
ABSTRACT
| FULL TEXT
Routine Pelvic and Lower Extremity CT Venography in Patients Undergoing Pulmonary CT Angiography
Hunsaker et al.
Am. J. Roentgenol. 2008;190:322-326.
ABSTRACT
| FULL TEXT
Computed Tomographic Pulmonary Angiography vs Ventilation-Perfusion Lung Scanning in Patients With Suspected Pulmonary Embolism: A Randomized Controlled Trial
Anderson et al.
JAMA 2007;298:2743-2753.
ABSTRACT
| FULL TEXT
Diagnosis of pulmonary embolism in hospitalised patients: retrospective survey of an institutional standard
Jouveshomme et al.
Eur Respir J 2007;30:1117-1123.
ABSTRACT
| FULL TEXT
Management of Suspected Acute Pulmonary Embolism in the Era of CT Angiography: A Statement from the Fleischner Society
Remy-Jardin et al.
Radiology 2007;245:315-329.
FULL TEXT
Very Low Probability Interpretation of V/Q Lung Scans in Combination with Low Probability Objective Clinical Assessment Reliably Excludes Pulmonary Embolism: Data from PIOPED II
Gottschalk et al.
JNM 2007;48:1411-1415.
ABSTRACT
| FULL TEXT
Elevation of plasma D-dimer is closely associated with venous thrombosis produced by double-lumen catheter in pre-dialysis patients
Kanno et al.
Nephrol Dial Transplant 2007;22:1224-1227.
ABSTRACT
| FULL TEXT
Bayes pulmonary embolism assisted diagnosis: a new expert system for clinical use
Luciani et al.
Emerg. Med. J. 2007;24:157-164.
ABSTRACT
| FULL TEXT
Deferral of assessment of pulmonary embolism
Siragusa et al.
haematol 2007;92:410-413.
ABSTRACT
| FULL TEXT
The Natural Course of Hemodynamically Stable Pulmonary Embolism: Clinical Outcome and Risk Factors in a Large Prospective Cohort Study
Nijkeuter et al.
Chest 2007;131:517-523.
ABSTRACT
| FULL TEXT
Diagnostic Pathways in Acute Pulmonary Embolism: Recommendations of the PIOPED II Investigators
Stein et al.
Radiology 2007;242:15-21.
FULL TEXT
Evidently...
Lehman
Evid. Based Med. 2006;11:167-167.
FULL TEXT
Clinical Year in Review II: Occupational Lung Disease, Pulmonary Vascular Disease, Bronchiectasis, and Chronic Obstructive Pulmonary Disease
Trow
Proc Am Thorac Soc 2006;3:557-560.
FULL TEXT
Acute Pulmonary Embolism: Part I: Epidemiology and Diagnosis
Piazza and Goldhaber
Circulation 2006;114:e28-e32.
FULL TEXT
An algorithm for managing suspected pulmonary embolism.
Takagi and Umemoto
JAMA 2006;295:2603-2604.
FULL TEXT
An evaluation of D-dimer in the diagnosis of pulmonary embolism: a randomized trial.
Kearon et al.
ANN INTERN MED 2006;144:812-821.
ABSTRACT
| FULL TEXT
Multidetector computed tomography for acute pulmonary embolism.
Stein et al.
NEJM 2006;354:2317-2327.
ABSTRACT
| FULL TEXT
Accuracy or outcome in suspected pulmonary embolism.
Perrier and Bounameaux
NEJM 2006;354:2383-2385.
FULL TEXT
Comparative accuracy: assessing new tests against existing diagnostic pathways.
Bossuyt et al.
BMJ 2006;332:1089-1092.
FULL TEXT
Sophia
Spencer and Wyatt
Emerg. Med. J. 2006;23:328-328.
FULL TEXT
Reliability of a pulmonary embolism management algorithm
Bari
Thorax 2006;61:347-347.
FULL TEXT
New Clinical Decision Strategy Effective for Excluding Pulmonary Embolism
JWatch Emergency Med. 2006;2006:5-5.
FULL TEXT
Venous thromboembolism: Potentially dangerous diagnostic pitfalls arise from diagnostic tests
Jolobe
BMJ 2006;332:364-364.
FULL TEXT
Simplified, Accurate PE Diagnosis
Journal Watch Cardiology 2006;2006:3-3.
FULL TEXT
More Help in Diagnosing Pulmonary Embolism
JWatch General 2006;2006:2-2.
FULL TEXT
What's new in the other general journals
Tonks
BMJ 2006;332:163-164.
FULL TEXT
Diagnosing Pulmonary Embolism With Improved Certainty and Simplicity
Hull
JAMA 2006;295:213-215.
FULL TEXT
|
