New diagnostic tests for pulmonary embolism,☆☆,

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Abstract

In 1990, the multicenter Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED), sponsored by the National Institutes of Health, compared the diagnostic value of the radioisotopic ventilation-perfusion lung scan (V/Q scan) with that of pulmonary angiography for the diagnosis of pulmonary embolism (PE). Despite the endurance of the radioisotopic V/Q scan as the most widely used test for evaluation of pulmonary embolism (PE), a better screening tool is clearly needed for use in the emergency department. During the past decade, several new modalities have emerged for evaluation of patients with suspected PE. We evaluate the diagnostic utility of the D -dimer test and the alveolar dead space determination as potential screening tests and of spiral computed tomography, magnetic resonance imaging, transthoracic echocardiography, and transesophageal echocardiography as potential confirmatory tests for PE. For comparison, recent data on the diagnostic utility of the alveolar-arterial oxygen gradient and the V/Q scan are included. The potential application of these new tests to a hypothetical ED population is described. [Kline JA, Johns KL, Colucciello SA, Israel EG. New diagnostic tests for pulmonary embolism. Ann Emerg Med. February 2000;35:168-180.]

Introduction

In 1990, the multicenter Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED), sponsored by the National Institutes of Health, compared the diagnostic value of the radioisotopic ventilation-perfusion lung scan (V/Q scan) with that of pulmonary angiography for the diagnosis of pulmonary embolism (PE).1 A comprehensive analysis of PIOPED data found the sensitivity of a normal or near-normal V/Q scan reading to be 99% and the specificity of a high-probability reading to be 98%.2 However, 78% of V/Q scans in the PIOPED study were read as intermediate, indeterminate, or low probability and therefore provided no firm diagnostic information without further testing. Moreover, the examination requires at least 2 hours to perform, patient transport out of the emergency department, and the injection of a γ-emitting radioisotope.

Despite the endurance of the V/Q scan as the most widely used test for evaluation of PE, a better screening tool is clearly needed for use in the ED. During the past decade, several promising new modalities have emerged for evaluation of patients with suspected PE. This systematic review first evaluates the diagnostic utility of the D -dimer test and the alveolar dead space determination as potential screening tests for PE. Second, we examine spiral computed tomography (sCT), magnetic resonance imaging (MRI), transthoracic echocardiography (TTE), and transesophageal echocardiography (TEE) as potential confirmatory tests for PE. For comparison, we included recent data on the diagnostic utility of the alveolar-arterial oxygen gradient (A –aDO2) and the V/Q scan.

The first objective of this review was to determine whether either of 2 new screening tests has sufficient sensitivity to reliably exclude PE in the ED. The second objective was to determine whether any of 4 new imaging tests has sufficient specificity to reliably confirm the diagnosis of PE. We specifically discuss the potential application of these new tests to a hypothetical ED population.

Section snippets

Materials and methods

Articles were identified through the use of computerized search bibliographies, including MEDLINE, EMBASE, LILACS, and HealthSTAR; hand searches of Index Medicus and Current Contents ; and review of published bibliographies. Retrieval was restricted to studies of human subjects in journals published in the English language from 1980 until May 1999. Abstracts, letters, editorials, reviews, case reports, and case series were excluded. Studies retrieved and discovered to duplicate previously

Results

The results for each test are presented in 3 parts: technique required to perform the test, summary of data, and critical analysis of data with attention to relevance to the practice of emergency medicine.

Implications for clinical practice

Based on the data presented in Table 1, Table 2 sufficient volume of class II evidence exists to support the use of second-generation D -dimer tests as part of a decision algorithm to screen for PE. One such model was proposed by Ginsberg et al,47 who found that only 1.0% of patients with a low clinical probability for PE and a negative SimpliRED D -dimer test result had a PE. Their report should be consulted for details regarding the definition of low clinical probability. Patients with a

Implications for research

First, because questions still arise about how to define a “low-risk” outpatient with suspected PE,36, 47, 121, 123 further research should focus on the use of a second-generation D -dimer assay in conjunction with an objective test of pulmonary gas exchange so that the combination of both tests decreases the posttest probability of PE to 1% in a multicenter sample of outpatients with suspected PE.

Second, TTE should be studied to determine whether specific parameters of right ventricular

Acknowledgements

We thank Robert L. Wears, MD, for his assistance with the statistical methods.

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    None of the authors have received funds from any private or public source for the explicit purpose of writing this article.

    ☆☆

    Two of the authors (JAK, EGI) are engaged in a multicenter trial involving the use of dead space and SimpliRED D -dimer measurements to screen for pulmonary embolism, the Rapid Exclusion of Pulmonary Embolism (REPE) study. The authors’ institutions receive a $100 stipend for each patient enrolled in the REPE study.

    Address for reprints: Jeffrey Kline, MD, Department of Emergency Medicine, MEB 304, Carolinas Medical Center, Charlotte, NC 28232-2861; 704-355-7092, fax 704-355-7047; E-mail [email protected].

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