Ali S. Raja, MD; Jeffrey O. Greenberg, MD; Amir Qaseem, MD, PhD, MHA; Thomas D. Denberg, MD, PhD; Nick Fitterman, MD; Jeremiah D. Schuur, MD, MHS; for the Clinical Guidelines Committee of the American College of Physicians *
Note: Best practice advice papers are “guides” only and may not apply to all patients and all clinical situations. Thus, they are not intended to override clinicians' judgment. All ACP best practice advice papers are considered automatically withdrawn or invalid 5 years after publication or once an update has been issued.
Disclaimer: The authors of this article are responsible for its contents, including any clinical or treatment recommendations.
Financial Support: Financial support for the development of this paper comes exclusively from the ACP operating budget.
Disclosures: Dr. Fitterman reports that he chairs the Test-Writing Committee for the secure examination of the American Board of Internal Medicine. Dr. Schuur reports that he chaired the Quality and Performance Committee of the American College of Emergency Physicians, in which capacity he helped to develop performance measures of appropriate use of computed tomography for pulmonary embolism. Authors not named here have disclosed no conflicts of interest. Authors followed the policy regarding conflicts of interest described at www.annals.org/article.aspx?articleid=745942. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-1772. A record of conflicts of interest is kept for each Clinical Guidelines Committee meeting and conference call and can be viewed at www.acponline.org/clinical_information/guidelines/guidelines/conflicts_cgc.htm.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer.
Requests for Single Reprints: Amir Qaseem, MD, PhD, MHA, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.
Current Author Addresses: Dr. Raja: Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114.
Drs. Greenberg and Schuur: Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115.
Dr. Qaseem: American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.
Dr. Fitterman: Hofstra North Shore Long Island Jewish School of Medicine, 270 Park Avenue, Huntington, NY 11743.
Dr. Denberg: Carilion Clinic, PO Box 13727, Roanoke, VA 24036.
Author Contributions: Conception and design: A.S. Raja, J.O. Greenberg, A. Qaseem, T.D. Denberg, N. Fitterman, J.D. Schuur.
Analysis and interpretation of the data: A.S. Raja, A. Qaseem, T.D. Denberg.
Drafting of the article: A.S. Raja, J.O. Greenberg, A. Qaseem, T.D. Denberg, N. Fitterman, J.D. Schuur.
Critical revision of the article for important intellectual content: A.S. Raja, J.O. Greenberg, A. Qaseem, T.D. Denberg, J.D. Schuur.
Final approval of the article: A.S. Raja, J.O. Greenberg, A. Qaseem, T.D. Denberg, N. Fitterman, J.D. Schuur.
Provision of study materials or patients: T.D. Denberg.
Statistical expertise: A. Qaseem, T.D. Denberg.
Obtaining of funding: A. Qaseem, T.D. Denberg.
Administrative, technical, or logistic support: A.S. Raja, A. Qaseem, T.D. Denberg, J.D. Schuur.
Collection and assembly of data: A.S. Raja, J.O. Greenberg, T.D. Denberg.
Pulmonary embolism (PE) can be a severe disease and is difficult to diagnose, given its nonspecific signs and symptoms. Because of this, testing patients with suspected acute PE has increased dramatically. However, the overuse of some tests, particularly computed tomography (CT) and plasma d-dimer measurement, may not improve care while potentially leading to patient harm and unnecessary expense.
The literature search encompassed studies indexed by MEDLINE (1966–2014; English-language only) and included all clinical trials and meta-analyses on diagnostic strategies, decision rules, laboratory tests, and imaging studies for the diagnosis of PE. This document is not based on a formal systematic review, but instead seeks to provide practical advice based on the best available evidence and recent guidelines. The target audience for this paper is all clinicians; the target patient population is all adults, both inpatient and outpatient, suspected of having acute PE.
Clinicians should use validated clinical prediction rules to estimate pretest probability in patients in whom acute PE is being considered.
Clinicians should not obtain d-dimer measurements or imaging studies in patients with a low pretest probability of PE and who meet all Pulmonary Embolism Rule-Out Criteria.
Clinicians should obtain a high-sensitivity d-dimer measurement as the initial diagnostic test in patients who have an intermediate pretest probability of PE or in patients with low pretest probability of PE who do not meet all Pulmonary Embolism Rule-Out Criteria. Clinicians should not use imaging studies as the initial test in patients who have a low or intermediate pretest probability of PE.
Clinicians should use age-adjusted d-dimer thresholds (age × 10 ng/mL rather than a generic 500 ng/mL) in patients older than 50 years to determine whether imaging is warranted.
Clinicians should not obtain any imaging studies in patients with a d-dimer level below the age-adjusted cutoff.
Clinicians should obtain imaging with CT pulmonary angiography (CTPA) in patients with high pretest probability of PE. Clinicians should reserve ventilation–perfusion scans for patients who have a contraindication to CTPA or if CTPA is not available. Clinicians should not obtain a d-dimer measurement in patients with a high pretest probability of PE.
Raja AS, Greenberg JO, Qaseem A, et al, for the Clinical Guidelines Committee of the American College of Physicians. Evaluation of Patients With Suspected Acute Pulmonary Embolism: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med. 2015;163:701–711. [Epub ahead of print 29 September 2015]. doi: https://doi.org/10.7326/M14-1772
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Published: Ann Intern Med. 2015;163(9):701-711.
Published at www.annals.org on 29 September 2015
Emergency Medicine, Guidelines, High Value Care, Hospital Medicine, Pulmonary Embolism.
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