Wim Lucassen, MD; Henk C. van Weert, MD, PhD; Harry Büller, MD, PhD
Potential Conflicts of Interest: Dr. Lucassen: Grant (money to institution): Dutch Heart Foundation. Dr. van Weert: Grant: Dutch Heart Foundation. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M11-0905.
Lucassen W., van Weert H., Büller H.; Clinical Decision Rules for Excluding Pulmonary Embolism. Ann Intern Med. 2012;156:169-170. doi: 10.7326/0003-4819-156-2-201201170-00025
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Published: Ann Intern Med. 2012;156(2):169-170.
We thank Dr. Giusti, Ms. Coerezza, and Ms. Cernuschi for their interesting remarks. Three important issues were addressed: whether a d-dimer test is needed in low-probability patients, the issue of false-positive CT results in low-risk patients, and the adequacy of the outcome measure.
A study by Stein and colleagues (1) reported that among patients with a low clinical probability of PE, 42% of CT scans were false-positive. However, the study included all patients with a Wells score less than 2, without using a d-dimer test. The Christopher Study Investigators (2) reported that nearly 50% of low-risk patients (Wells score, 4) had a negative d-dimer test result and were not referred for CT. Using a d-dimer test in combination with a clinical decision rule will significantly reduce the number of low-risk patients referred for CT. Choosing the Wells rule with a high cutoff (Wells score, 4) will increase specificity and further decrease the number of referred patients. In our meta-analysis, we showed the safety of such a strategy.
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