Is a normal computed tomography pulmonary angiography safe to rule out acute pulmonary embolism in patients with a likely clinical probability?

Tom van der Hulle; Nick van Es; Paul L. den Exter; Josien van Es; Inge C. M. Mos; Renée A. Douma; Marieke J. H. A. Kruip; Marcel M. C. Hovens; Marije ten Wolde; Mathilde Nijkeuter; Hugo ten Cate; Pieter W. Kamphuisen; Harry R. Büller; Menno V. Huisman; Frederikus A. Klok

doi:10.1160/TH17-02-0076

Thrombosis and Haemostasis, Table of Contents

Thromb Haemost 2017; 117(08): 1622-1629
DOI: 10.1160/TH17-02-0076

Stroke, Systemic or Venous Thromboembolism

Schattauer GmbH

Is a normal computed tomography pulmonary angiography safe to rule out acute pulmonary embolism in patients with a likely clinical probability?

A patient-level meta-analysis

Tom van der Hulle

¹Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands

,

Nick van Es

²Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands

,

Paul L. den Exter

¹Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands

,

Josien van Es

²Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands

,

Inge C. M. Mos

¹Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands

,

Renée A. Douma

²Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands

,

Marieke J. H. A. Kruip

³Department of Hematology, Erasmus University Medical Center, Rotterdam, the Netherlands

,

Marcel M. C. Hovens

⁴Department of Internal Medicine, Rijnstate Hospital, Arnhem, the Netherlands

,

Marije ten Wolde

⁵Department of Internal Medicine, Flevoziekenhuis Hospital, Almere, the Netherlands

,

Mathilde Nijkeuter

⁶Department of Internal Medicine, University Medical Center Utrecht, Utrecht, the Netherlands

,

Hugo ten Cate

⁷Department of Internal Medicine and Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, The Netherlands

⁸Department of Internal Medicine and Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, the Netherlands

,

Pieter W. Kamphuisen

⁹Department of Vascular Medicine, University Medical Center Groningen, Groningen, the Netherlands

,

Harry R. Büller

²Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands

,

Menno V. Huisman

¹Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands

,

Frederikus A. Klok

¹Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands

› Author Affiliations

Abstract

Summary

A normal computed tomography pulmonary angiography (CTPA) remains a controversial criterion for ruling out acute pulmonary embolism (PE) in patients with a likely clinical probability. We set out to determine the risk of VTE and fatal PE after a normal CTPA in this patient category and compare these risk to those after a normal pulmonary angiogram of 1.7% (95%CI 1.0–2.7%) and 0.3% (95%CI 0.02–0.7%). A patient-level meta-analysis from 4 prospective diagnostic management studies that sequentially applied the Wells rule, D-dimer tests and CTPA to consecutive patients with clinically suspected acute PE. The primary outcome was the 3-month VTE incidence after a normal CTPA. A total of 6,148 patients were included with an overall PE prevalence of 24%. The 3-month VTE incidence in all 4,421 patients in whom PE was excluded at baseline was 1.2% (95%CI 0.48–2.6) and the risk of fatal PE was 0.11% (95%CI 0.02–0.70). In patients with a likely clinical probability the 3-month incidences of VTE and fatal PE were 2.0% (95%CI 1.0–4.1%) and 0.48% (95%CI 0.20–1.1%) after a normal CTPA. The 3-month incidence of VTE was 6.3% (95%CI 3.0–12) in patients with a Wells rule >6 points. In conclusion, this study suggests that a normal CTPA may be considered as a valid diagnostic criterion to rule out PE in the majority of patients with a likely clinical probability, although the risk of VTE is higher in subgroups such as patients with a Wells rule >6 points for which a closer follow-up should be considered.

Supplementary Material to this article is available online at www.thrombosis-online.com.

Keywords

Pulmonary embolism - computed tomography - diagnosis - safety

Full Text

References

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Supplementary Material

Online Supplementary Material (PDF)