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Use of a Clinical Model for Safe Management of Patients with Suspected Pulmonary Embolism

Philip S. Wells, MD, MSc; Jeffrey S. Ginsberg, MD; David R. Anderson, MD; Clive Kearon, MD, PhD; Michael Gent, MSc; Alexander G. Turpie, MD; Janis Bormanis, MD; Jeffrey Weitz, MD; Michael Chamberlain, MD; Dennis Bowie, MD; David Barnes, MD; and Jack Hirsh, MD
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Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1998;129(12):997-1005. doi:10.7326/0003-4819-129-12-199812150-00002
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Background: The low specificity of ventilation-perfusion lung scanning complicates the management of patients with suspected pulmonary embolism.

Objective: To determine the safety of a clinical model for patients with suspected pulmonary embolism.

Design: Prospective cohort study.

Setting: Five tertiary care hospitals.

Patients: 1239 inpatients and outpatients with suspected pulmonary embolism.

Interventions: A clinical model categorized pretest probability of pulmonary embolism as low, moderate, or high, and ventilation-perfusion scanning and bilateral deep venous ultrasonography were done. Testing by serial ultrasonography, venography, or angiography depended on pretest probability and lung scans.

Measurements: Patients were considered positive for pulmonary embolism if they had an abnormal pulmonary angiogram, abnormal ultrasonogram or venogram, high-probability ventilation-perfusion scan plus moderate or high pretest probability, or venous thromboembolic event during the 3-month follow-up. All other patients were considered negative for pulmonary embolism. Rates of pulmonary embolism during follow-up in patients who had a normal lung scan and those with a non-high-probability scan and normal serial ultrasonogram were compared.

Results: Pretest probability was low in 734 patients (3.4% with pulmonary embolism), moderate in 403 (27.8% with pulmonary embolism), and high in 102 (78.4% with pulmonary embolism). Three of the 665 patients (0.5% [95% CI, 0.1% to 1.3%]) with low or moderate pretest probability and a non-high-probability scan who were considered negative for pulmonary embolism had pulmonary embolism or deep venous thrombosis during 90-day follow-up; this rate did not differ from that in patients with a normal scan (0.6% [CI, 0.1% to 1.8%]; P > 0.2).

Conclusion: Management of patients with suspected pulmonary embolism on the basis of pretest probability and results of ventilation-perfusion scanning is safe.


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Figure 1.
Algorithm for the clinical model to determine the pretest probability of pulmonary embolism (PE).

Respiratory points consist of dyspnea or worsening of chronic dyspnea, pleuritic chest pain, chest pain that is nonretrosternal and nonpleuritic, an arterial oxygen saturation less than 92% while breathing room air that corrects with oxygen supplementation less than 40%, hemoptysis, and pleural rub. Risk factors are surgery within 12 weeks, immobilization (complete bedrest) for 3 or more days in the 4 weeks before presentation, previous deep venous thrombosis or objectively diagnosed pulmonary embolism, fracture of a lower extremity and immobilization of the fracture within 12 weeks, strong family history of deep venous thrombosis or pulmonary embolism (two or more family members with objectively proven events or a first-degree relative with hereditary thrombophilia), cancer (treatment ongoing, within the past 6 months, or in the palliative stages), the postpartum period, and lower-extremity paralysis. JVP = jugular venous pressure; RBBB = right bundle-branch block.

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Grahic Jump Location
Figure 2.
Diagnostic strategy used in patients with suspected pulmonary embolism.
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Figure 3.
Algorithm for investigation of patients with suspected deep venous thrombosis or pulmonary embolism during 3-month follow-up.
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Figure 4.
Results of ultrasonography in patients with non-high-probability ventilation-perfusion scans and low or moderate pretest probability of pulmonary embolism.
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