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Appropriateness of Diagnostic Management and Outcomes of Suspected Pulmonary Embolism

Pierre-Marie Roy, MD, PhD; Guy Meyer, MD; Bruno Vielle, MD, PhD; Catherine Le Gall, MD; Franck Verschuren, MD; Françoise Carpentier, MD; Philippe Leveau, MD; Alain Furber, MD, PhD, EMDEPU Study Group*
[+] Article and Author Information

From Centre Hospitalier Universitaire, Angers, France; Hôpital Européen Georges Pompidou, Paris, France; Centre Hospitalier Général, Argenteuil, France; Cliniques Universitaires Saint Luc, Brussels, Belgium; Centre Hospitalier Universitaire, Grenoble, France; and Centre Hospitalier Nord Deux-Sèvres, Thouars, France.


Acknowledgments: The authors thank the members of the EMDEPU Study Group and Céline Priou for skilled assistance. They also thank the emergency department residents and all of the physicians who contributed to the management of the patients for their invaluable help throughout the study.

Grant Support: By a grant from the clinical research department of Pays de la Loire (Projet régional Hospitalier de Recherche Clinique).

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Pierre-Marie Roy, MD, PhD, Service d'Accueil et Traitement des Urgences, Centre Hospitalier Universitaire, 4 rue Larrey, 49033 Angers Cedex 01, France; e-mail, PMRoy@chu-angers.fr.

Current Author Addresses: Dr. Roy: Service d'Accueil et Traitement des Urgences, Centre Hospitalier Universitaire, 4 rue Larrey, 49033 Angers Cedex 01, France.

Dr. Meyer: Service de Pneumologie, Hôpital Européen Georges Pompidou, 20 rue Leblanc, 75908 Paris Cedex 15, France.

Dr. Vielle: Département de Statistique, Centre Hospitalier Universitaire, 4 rue Larrey, 49033 Angers Cedex 01, France.

Dr. Le Gall: Service des Urgences, Centre Hospitalier Général, 69 rue du Colonel Prudhon, 95107 Argenteuil, France.

Dr. Verschuren: Département d'Urgence et de Reanimation, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, 10 avenue Hippocrate, B-1200 Bruxelles, Belgium.

Dr. Carpentier: Service d'Accueil et d'Urgences, Hôpital Albert Michallon, CHU Grenoble, 38700 La Tronche, France.

Dr. Leveau: Service des Urgences, Centre Hospitalier Nord Deux-Sèvres, Center de Thouars, 35 Boulevard Auguste Rodin, 79100 Thouars, France.

Dr. Furber: Service de Cardiologie, Centre Hospitalier Universitaire, 4 rue Larrey, 49033 Angers Cedex 01, France.

Author Contributions: Conception and design: P.-M. Roy, C. Le Gall.

Analysis and interpretation of the data: P.-M. Roy, G. Meyer, B. Vielle, C. Le Gall, P. Leveau, A. Furber.

Drafting of the article: P.-M. Roy, G. Meyer.

Critical revision of the article for important intellectual content: G. Meyer, B. Vielle, C. Le Gall, A. Furber.

Final approval of the article: P.-M. Roy, G. Meyer, B. Vielle, C. Le Gall, F. Verschuren, F. Carpentier, P. Leveau, A. Furber.

Provision of study materials or patients: P.-M. Roy, G. Meyer, C. Le Gall, F. Verschuren, F. Carpentier.

Statistical expertise: B. Vielle.

Obtaining of funding: P.-M. Roy.

Administrative, technical, or logistic support: G. Meyer.

Collection and assembly of data: P.-M. Roy, C. Le Gall, F. Verschuren, F. Carpentier, P. Leveau, A. Furber.


Ann Intern Med. 2006;144(3):157-164. doi:10.7326/0003-4819-144-3-200602070-00003
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In our nationwide study of emergency departments, routine diagnostic practice for suspected pulmonary embolism differed greatly from evidence-based guidelines, and the appropriateness of the diagnostic criteria strongly correlated with patient outcomes. In a majority of patients in whom pulmonary embolism was excluded by the initial evaluation, diagnostic criteria did not adhere to guidelines. The risk for thromboembolism during follow-up was 6-fold higher in these patients than in those who received appropriate management. Of note, proper management was found to be hampered in institutions that lacked a written diagnostic algorithm that included a method for scoring the clinical probability of pulmonary embolism.

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Figures

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Figure 1.
Flow chart summarizing the diagnostic process and 3-month outcomes.
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Figure 2.
Judgment criteria used to classify each diagnostic process as appropriate or inappropriate according to international guidelines.

A diagnostic process was considered to be appropriate when the results of the tests performed corresponded to those mentioned in the box. All other strategies were considered to be inappropriate. Positive ultrasonography results are defined as incompressibility of a proximal leg vein (popliteal or supra); positive echocardiography results refer to the presence of acute right ventricular dilatation. CT = computed tomography; ELISA = enzyme-linked immunosorbent assay; PA = pulmonary angiography; PE = pulmonary embolism.

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Comments

Submit a Comment
Appropriatness of excluding pulmonary embolism
Posted on February 15, 2006
Herman MA Hofstee
Free University Academic Medical Center
Conflict of Interest: None Declared

Dear Sir,

I read with great interest the study of Roy et al. However there is one thing that puzzled me. In figure 2 the authors state that pulmonary embolism (PE) had appropriately been ruled out when a spiral CT and ELISA D-dimer results were negative in the low clinical probability group and that only a negative D-dimer result is sufficient to rule out PE in the high probability group. From basic epidemiology and studies concerning the value of d-dimer in the diagnosis of pulmonary embolism we know that a negative d-dimer provides high certainty for excluding PE (low post-test probability of PE). On the other hand a negative D-dimer in a group with a high a-priori chance is insufficient to rule out PE (higher post-test probability of PE)(1). Could a print error have been occured?

1) Stein PD, Hull RD, Patel KC, Olson RE, Ghali WA, Brant R et al. D- dimer for the exclusion of acute venous thrombosis and pulmonary embolism: a systematic review. Ann Intern Med 2004; 140(8):589-602.

Conflict of Interest:

None declared

Appropriateness of excluding pulmonary embolism - In response :
Posted on April 14, 2006
Pierre-Marie Roy
University Hospital of Angers, France
Conflict of Interest: None Declared

Dear sir,

Doctor Hofstee's remark is well-done. We indeed considered as appropriate the exclusion of pulmonary embolism on the basis of a negative ELISA D-dimer test even in patients with a high pretest probability because it was part of the recommendations of the European Society of Cardiology (1). We acknowledge that this criterion for excluding PE is debatable in an Evidence Based Medicine point of view (2). It has been evaluated in large outcomes studies (3, 4) but only a few patients had the combination of a high pretest probability and a negative ELISA D-dimer test.(5) As a general rule, we considered as appropriate all diagnostic strategies that have been selected by international experts. The low rate of recurrent PE in the group of patients with an exclusion strategy based on these recommendations in our study reinforces this choice. Even with such a liberal definition only 57% of the patients underwent an appropriate diagnostic strategy and this was even lower when pulmonary embolism was excluded. Using more stringent criteria for appropriateness would have further reduced the rate of appropriate diagnostic strategies and would have reinforced our conclusion that the diagnosis of pulmonary embolism in clinical practice is far from optimal.

Pierre-Marie Roy and Guy Meyer

Reference

1. Guidelines on diagnosis and management of acute pulmonary embolism. Task Force on Pulmonary Embolism, European Society of Cardiology. Eur Heart J. 2000;21(16):1301-36.

2. Roy PM, Colombet I, Durieux P, Chatellier G, Sors H, Meyer G. Systematic review and meta-analysis of strategies for the diagnosis of suspected pulmonary embolism. Bmj. 2005;331(7511):259.

3. Perrier A, Desmarais S, Miron MJ, et al. Non-invasive diagnosis of venous thromboembolism in outpatients. Lancet. 1999;353(9148):190-5.

4. Perrier A, Roy PM, Aujesky D, et al. Diagnosing pulmonary embolism in outpatients with clinical assessment, D-dimer measurement, venous ultrasound, and helical computed tomography: a multicenter management study. Am J Med. 2004;116(5):291-9.

5. Righini M, Aujesky D, Roy PM, et al. Clinical usefulness of d- dimer depending on clinical probability and cutoff value in outpatients with suspected pulmonary embolism. Arch Intern Med. 2004;164(22):2483-7.

Conflict of Interest:

None declared

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Summary for Patients

Emergency Room Management of Patients with Suspected Pulmonary Embolism

The summary below is from the full report titled “Appropriateness of Diagnostic Management and Outcomes of Suspected Pulmonary Embolism.” It is in the 7 February 2006 issue of Annals of Internal Medicine (volume 144, pages 157-164). The authors are P.-M. Roy, G. Meyer, B. Vielle, C. Le Gall, F. Verschuren, F. Carpentier, P. Leveau, and A. Furber, for the EMDEPU Study Group.

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