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Using Clinical Evaluation and Lung Scan to Rule Out Suspected Pulmonary Embolism
Is It a Valid Option in Patients With Normal Results of Lower-Limb Venous Compression Ultrasonography?
Arnaud Perrier, MD;
Marie-José Miron, MD;
Sylvie Desmarais, MD;
Philippe de Moerloose, MD;
Daniel Slosman, MD;
Dominique Didier, MD;
Pierre-François Unger, MD;
Alain Junod, MD;
Jean-Victor Patenaude, MD;
Henri Bounameaux, MD
Arch Intern Med. 2000;160:512-516.
Background In patients with a low clinical probability of pulmonary embolism (PE) and a nondiagnostic lung scan, the prevalence of PE is theoretically very low. We assessed the safety and usefulness of this association for ruling out PE .
Methods We analyzed data from 2 consecutive cohort management studies performed in 2 university hospitals (Geneva University Hospital, Geneva, Switzerland, and Hôpital Saint-Luc, Montreal, Quebec), which enrolled 1034 consecutive patients who came to the emergency department with clinically suspected PE. All patients were submitted to a sequential diagnostic protocol of lung scan, D-dimer testing, lower-limb venous compression ultrasonography (US), and pulmonary angiography in case of inconclusive results of noninvasive workup.
Results The prevalence of PE was 27.6%. Empirical assessment was accurate for identifying patients with a low likelihood of PE (8.2% prevalence of PE in the low clinical probability category). One hundred eighty patients had a low clinical probability of PE and a nondiagnostic lung scan. Among these patients, US showed deep vein thrombosis in 5. Hence, PE could be ruled out by a low clinical probability, a nondiagnostic lung scan, and a normal US in 175 patients (21.5%). The 3-month thromboembolic risk in these patients was low (1.7%; 95% confidence interval, 0.4%-4.9%).
Conclusions Anticoagulant treatment could be safely withheld in patients with a low clinical probability of PE and a nondiagnostic lung scan, provided that the US is normal. This combination of findings avoided pulmonary angiography in 21.5% of patients with suspected PE in this series.
From the Medical Clinic 1 (Drs Perrier and Junod), Divisions of Angiology and Hemostasis (Drs Miron, de Moerloose, and Bounameaux), Nuclear Medicine (Dr Slosman), Radiodiagnostic and Interventional Radiology (Dr Didier), and Medical and Surgical Emergency (Dr Unger), Geneva University Hospital, Geneva, Switzerland; and the Department of Internal and Vascular Medicine, Hôpital Saint-Luc, University of Montreal, Quebec (Drs Desmarais and Patenaude).
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