Diagnosis of Pulmonary Embolism

ABSTRACT

Conventional pulmonary arteriography for the diagnosis of pulmonary embolism (PE) bears several limitations in clinical practice, basically due to its invasiveness. On the other hand, no single noninvasive test is both sensitive and specific for the diagnosis of PE. Therefore, the choice of available noninvasive diagnostic tests guided by the clinical probability of PE is a good compromise at present. The first necessary step toward the diagnosis of PE is to raise the clinical suspicion, given that no diagnosis can be made if PE is not considered in the differential diagnosis of patients with acute cardiorespiratory symptoms. Second, empirical or standardized rules for predicting clinical probability may be combined with one or more noninvasive tests with the aim of increasing the accuracy of the noninvasive diagnosis. The strategy for the noninvasive diagnosis of PE varies among different centers according to the availability of each single technique that may be integrated with another and according to the characteristics of the population that refers to each single center. Therefore, spiral CT should not be used as a primary tool for the diagnosis of PE; its role needs to be re-evaluated in light of its sensitivity, feasibility, and radiation burden on the patients. In patients in whom the diagnosis of PE cannot be made at the end of the noninvasive pathway, the use of the invasive techniques must be taken into consideration. In our experience, however, such cases should not exceed 15 to 20% of the total patient population.

Pulmonary embolism - clinical suspicion - clinical probability - noninvasive techniques - diagnostic algorithms

REFERENCES

• 1 Dalen J E, Alpert J S. Natural history of pulmonary embolism.  Prog Cardiovasc Dis. 1975;  17 259-270
• 2 Torbicki A, Van Beek J R, Charbonnier B et al.. Task force report. Guidelines on diagnosis and management of acute pulmonary embolism.  Eur Heart J. 2000;  21 1301-1335
• 3 Barrit D W, Jordan S C. Anticoagulant drugs in treatment of pulmonary embolism: a controlled trial.  Lancet. 1960;  1 1309-1312
• 4 Goldhaber S Z. Thrombolysis for pulmonary embolism.  Prog Cardiovasc Dis. 1991;  34 113-134
• 5 Giuntini C, Di Ricco G, Marini C, Melillo E, Palla A. Epidemiology of pulmonary embolism.  Chest. 1995;  107 3s-9s
• 6 Goldhaber S Z, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the international Cooperative Pulmonary Embolism Registry (ICOPER).  Lancet. 1999;  353 1386-1389
• 7 Goldhaber S Z, Hennekens C H, Evans D A et al.. Factors influencing the correct antemortem diagnosis of major pulmonary embolism.  Am J Med. 1982;  73 822-826
• 8 Morpurgo M, Schmidt C. Clinico-pathological correlations in pulmonary embolism: a posteriori evaluation.  Progr Respir Res. 1980;  13 8-15
• 9 Bergqvist D, Lindblad B. A 30-year survey of pulmonary embolism verified at autopsy: an analysis of 1,274 surgical patients.  Br J Surg. 1985;  72 105-108
• 10 Lilienfeld D E, Godbold J H, Burke G L et al.. Hospitalization and case fatality for pulmonary embolism in the twin cities: 1979-1984.  Am Heart J. 1990;  120 392-395
• 11 Palla A, Petruzzelli S, Donnamaria V, Giuntini C. The role of suspicion in the diagnosis of pulmonary embolism.  Chest. 1995;  107 21s-24s
• 12 Stein P D, Athanasoulis C, Alavi A et al.. Complications and validity of pulmonary angiography in acute pulmonary embolism.  Circulation. 1992;  85 462-468
• 13 Wells P S, Anderson D R, Rodger M et al.. Derivation of a simple clinical model to categorize patients' probability of pulmonary embolism: increasing the model's utility with the SimpliRED D-dimer.  Thromb Haemost. 2000;  83 416-420
• 14 Wicki J, Perneger T V, Junod A F, Bounameaux H, Perrier A. Assessing clinical probability of pulmonary embolism in the emergency ward: a simple score.  Arch Intern Med. 2001;  161 92-97
• 15 Miniati M, Monti S, Bottai M. A structured clinical model for predicting the probability of pulmoary embolism.  Am J Med. 2003;  114 173-179
• 16 British Thoracic Society Standards of Care Committee Pulmonary Embolism Guideline Development Group . British Thoracic Society guidelines for the management of suspected acute pulmonary embolism.  Thorax. 2003;  58 470-483
• 17 Petruzzelli S, Palla A, Citi M, Giuntini C. Improvement of screening for pulmonary embolism with a standardized questionnaire.  Respiration. 1990;  57 329-337
• 18 Celi A, Palla A, Petruzzelli S et al.. Prospective study of a standardized questionnaire to improve clinical estimate of pulmonary embolism.  Chest. 1989;  95 332-337
• 19 Palla A, Donnamaria V, Petruzzelli S, Rossi G, Riccetti G, Giuntini C. Enlargement of the right descending pulmonary artery in pulmonary embolism.  AJR Am J Roentgenol. 1983;  141 513-517
• 20 Palla A, Petruzzelli S, Donnamaria V, Rossi G, Maltinti G, Giuntini C. Radiographic assessment of perfusion impairment in pulmonary embolism.  Eur J Radiol. 1985;  5 252-255
• 21 Petruzzelli S, Palla A, Pieraccini F, Donnamaria V, Giuntini C. Routine electrocardiography in screening for pulmonary embolism.  Respiration. 1986;  50 233-243
• 22 Wells P S, Anderson D R, Rodger M et al.. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model an D-dimer.  Ann Intern Med. 2001;  135 98-107
• 23 Lee A Y, Ginsberg J S. Laboratory diagnosis of venous thromboembolism.  Baillieres Clin Haematol. 1998;  11 587-604
• 24 Perrier A, Desmarais S, Miron M J et al.. Non-invasive diagnosis of venous thromboembolism in outpatients.  Lancet. 1999;  353 190-195
• 25 Girard P, Decousus M, LaPorte S et al.. Diagnosis of pulmonary embolism in patients with proximal deep vein thrombosis: specificity of symptoms and perfusion defects at baseline and during anticoagulant therapy.  Am J Respir Crit Care Med. 2001;  164 1033-1037
• 26 Hull R D, Hirsh J, Carter C J et al.. Pulmonary angiography, ventilation lung scanning and venography for clinically suspected pulmonary embolism with abnormal perfusion lung scan.  Ann Intern Med. 1983;  98 891-899
• 27 Kearon C, Ginsberg J S, Hirsh J. The role of venous ultrasonography in the diagnosis of suspected deep venous thrombosis and pulmonary embolism.  Ann Intern Med. 1998;  129 1044-1049
• 28 Goldhaber S Z. Echocardiography in the management of pulmonary embolism.  Ann Intern Med. 2002;  136 691-700
• 29 Leibowitz D. Role of echocardiography in the diagnosis and treatment of acute pulmonary thromboembolism.  J Am Soc Echocardiogr. 2001;  14 921-926
• 30 Grifoni S, Olivotto I, Cecchini P et al.. Utility of an integrated clinical, echocardiographic, and venous ultrasonographic approach for traige of patients with suspected pulmonary embolism.  Am J Cardiol. 1998;  82 1230-1235
• 31 Jardin F, Dubourg O, Bourdarias J P. Echocardiographic pattern of acute cor pulmonale.  Chest. 1997;  111 209-217
• 32 Miniati M, Monti S, Pratali L et al.. Value of transthoracic echocardiography in the diagnosis of pulmonary embolism: results of a prospective study in unselected patients.  Am J Med. 2001;  110 528-535
• 33 Kasper W, Konstantinides S, Geibel A, Tiede N, Krause T, Just H. Prognostic significance of right ventricular afterload stress detected by echocardiology in patients with clinically suspected pulmonary embolism.  Heart. 1997;  77 346-349
• 34 Grifoni S, Olivotto I, Cecchini P et al.. Short-term clinical outcome of patients with acute pulmonary embolism, normal blood pressure, and echocardiographic right ventricular dysfunction.  Circulation. 2000;  101 2817-2822
• 35 Van Beek E J, Kuyer P M, Schenk B E, Brandjes D P, ten Cate J W, Büller H R. A normal perfusion lung scan in patients with clinically suspected pulmonary embolism: frequency and clinical validity.  Chest. 1995;  108 170-173
• 36 Pistolesi M, Miniati M. Imaging techniques in treatment algorithms of pulmonary embolism.  Eur Respir J Suppl. 2002;  35 28s-39s
• 37 Pistolesi M, Pupi A. Pulmonary embolism diagnosis.  Q J Nucl Med. 2001;  45 277-280
• 38 Taplin G V, Dore E K, Poe N D, Swanson L A, Johnson D E, Greenberg A. Radioisotope lung scanning in pulmonary disease.  J Miss State Med Assoc. 1966;  7 513-525
• 39 Miniati M, Pistolesi M, Marini C et al.. Value of perfusion lung scan in the diagnosis of pulmonary embolism: results of the Prospective Investigative Study of Acute Pulmonary Embolism Diagnosis (PISA-PED).  Am J Respir Crit Care Med. 1996;  154 1387-1393
• 40 Giuntini C, Fazio F, Santolicandro A M, Navalesi R. The scintigraphic determination of regional lung perfusion.  J Nucl Biol Med. 1968;  12 146-151
• 41 PIOPED Investigators . Value of the ventilation-perfusion scan in acute pulmonary embolism: results of the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED).  JAMA. 1990;  263 2753-2759
• 42 Giuntini C. Ventilation/perfusion scan and dead space in pulmonary embolism: are they useful for the diagnosis?.  Q J Nucl Med. 2001;  45 281-286
• 43 ACCP . American College of Chest Physicians . Consensus Committee on Pulmonary Embolism. Opinions regarding the diagnosis and management of venous thromboembolic disease.  Chest. 1998;  113 499-504
• 44 Giordano A, Angiolillo D J. Current role of lung scintigraphy in pulmonary embolism.  Q J Nucl Med. 2001;  45 294-301
• 45 Palla A, Giuntini C. Diagnosis of pulmonary embolism: have we reached our goal?.  Respiration. 2004;  71 22-23
• 46 Miniati M, Prediletto R, Formichi B et al.. Accuracy of clinical assessment in the diagnosis of pulmonary embolism.  Am J Respir Crit Care Med. 1999;  159 864-871
• 47 Miniati M, Pistolesi M. Assessing the clinical probability of pulmonary embolism.  Q J Nucl Med. 2001;  45 287-293
• 48 Eisner M D. Before diagnostic testing for pulmonary embolism: estimating the prior probability of disease.  Am J Med. 2003;  114 232-234
• 49 Remy-Jardin M, Tillie-Leland I, Shapiro D et al.. CT angiography of pulmonary embolism in patients with underlying respiratory disease: impact of multisided CT on image quality and negative predictive value.  Eur Radiol. 2002;  12 1971-1978
• 50 Rathbun S W, Raskob G E, Whitsett T L. Sensitivity and specificity of helical computed tomography in the diagnosis of pulmonary embolism: a systematic review.  Ann Intern Med. 2000;  132 227-232
• 51 Hiorns M P, Mayo J R. Spiral computed tomography for acute pulmonary embolism.  Can Assoc Radiol J. 2002;  53 258-268
• 52 Russo V, Piva T, Lovato L, Fattori R, Gavelli G. Multidetector CT: a new gold standard in the diagnosis of pulmonary embolism? State of the art and diagnostic algotithms.  Radiol Med (Torino). 2005;  109 49-63
• 53 Oser R F, Zuckerman D A, Gutierrez F R, Brink J A. Anatomic distribution of pulmonary emboli at pulmonary angiography: implications for cross-sectional imaging.  Radiology. 1996;  199 31-35
• 54 Ghaye B, Shapiro D, Mastora I et al.. Peripheral pulmonary arteries: how far in the lung does multi-detector row spiral CT allow analysis?.  Radiology. 2001;  219 629-636
• 55 Schoepf U, Holzknecht N, Helmberger T K et al.. Sub-segmental pulmonary emboli: improved detection with thin-collimation multi-detector row spiral CT.  Radiology. 2002;  222 483-490
• 56 Baile E, King G G, Muller N L et al.. Spiral computed tomography is comparable to angiography for the diagnosis of pulmonary embolism.  Am J Respir Crit Care Med. 2000;  161 1010-1015
• 57 Royal College of Radiologists .Making the Best Use of a Department of Clinical Radiology. Guidelines for Doctors. 5th ed. London, UK; Royal College of Radiologists 2003
• 58 Rydberg J, Kopecky K K, Fleiter T R. Multislice CT improves diagnosis, management of aortic disease.  Diagn Imaging (San Franc). 2000;  22 159-163
• 59 Fedullo P F, Tapson V F. The evaluation of suspected pulmonary embolism.  N Engl J Med. 2003;  349 1247-1256