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Pulmonary embolism (PE) is a difficult diagnosis to make or exclude and there have been various pretest probability scoring systems developed to aid the clinician in this area. However, these scoring systems do not take into account underlying cardiopulmonary abnormalities. This interesting study by Monreal et al looked at the diagnosis of PE in patients with congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD).
From a total of 4444 patients with proven PE enrolled in a registry, 14% had COPD and 9.5% had CHF. Using the Geneva scoring system, a lower percentage of patients with PE with COPD or CHF fell into the low pretest probability category (RR 0.82, 95% CI 0.66 to 1.02 and RR 0.73, 95% CI 0.56 to 0.95, respectively). The percentage of patients with a high probability of PE was similar among the three patient groups (CHF, COPD and neither). Using the Pisa score, the frequency of patients with COPD and CHF with a high pretest probability for PE were higher (61% and 72%, respectively). The Wells score was not used as the patient registry did not identify “an alternative diagnosis more likely than PE”.
The authors conclude that there are significant differences in the presentation of patients with PE who do and do not have coexistent COPD or CHF and that the performance of the various scoring systems varies. Physicians dealing with suspected PE should consider the underlying cardiopulmonary diagnoses and make necessary allowances when planning investigations and management.