Prediction of Pulmonary Embolism Extent by Clinical Findings, D-dimer Level and Deep Vein Thrombosis Shown by Ultrasound

Cécile Galle; Jean-Pierre Papazyan; Marie-José Miron; Daniel Slosman; Henri Bounameaux; Arnaud Perrier

doi:10.1055/s-0037-1616044

Thrombosis and Haemostasis, Table of Contents

Thromb Haemost 2001; 86(05): 1156-1160
DOI: 10.1055/s-0037-1616044

Review Article

Schattauer GmbH

Prediction of Pulmonary Embolism Extent by Clinical Findings, D-dimer Level and Deep Vein Thrombosis Shown by Ultrasound

Cécile Galle

¹Division of Angiology and Hemostasis, Geneva, Switzerland

,

Jean-Pierre Papazyan

²Division of Nuclear Medicine, Geneva, Switzerland

,

Marie-José Miron

¹Division of Angiology and Hemostasis, Geneva, Switzerland

,

Daniel Slosman

²Division of Nuclear Medicine, Geneva, Switzerland

,

Henri Bounameaux

¹Division of Angiology and Hemostasis, Geneva, Switzerland

,

Arnaud Perrier

³Medical Clinic 1, Geneva University Hospital, Geneva, Switzerland

› Author Affiliations

Abstract

Summary

Pulmonary embolism (PE) may encompass a wide spectrum of severity. To determine whether clinical findings, D-dimer (DD) concentration, and deep vein thrombosis (DVT) shown by lower-limb venous compression ultrasonography (US) might predict the scintigraphic extent of PE, we studied 104 hemodynamically stable consecutive outpatients with acute PE diagnosed by a high-probability ventilation-perfusion lung scan. Scintigraphic extent of PE was classified into three categories: perfusion defects corresponding to <30%, 30–50%, or >50% of the total lung area. Median respiratory and heart rates were found to be significantly related to the extent of PE. Higher median alveolar-arterial oxygen difference values were observed as the proportion of lung perfusion defects increased (>50% vs. <30%, 6.3 vs. 3.6 kPa, P <.0001). Median plasma DD concentration was 7950 g/L in patients with >50% perfusion defects compared to 2731 g/L in those with <30% defects (P = .0001). DD levels above 4000 g/L were associated to more extensive perfusion defects (>50% vs. <30% defects, OR 30; 95% CI 5.8–155). Finally, a proximal DVT was more likely among patients with larger perfusion defects (>50% vs. <30% defects, OR 4.5; 95% CI 1.5–13.6). In conclusion, clinical signs such as tachypnea and tachycardia, alveolar-arterial oxygen difference, plasma DD concentration, and presence of DVT on US are predictors of a larger PE, as assessed by the extent of perfusion defects on high probability lung scans.

Keywords

Pulmonary embolism - lung scan - prognosis

Full Text

References

References
1 Stein PD, Henry JW. Clinical characteristics of patients with acute pulmonary embolism stratified according to their presenting syndromes. Chest 1997; 112: 974-9.
2 Dalen JE, Haffajee CI, Alpert JS, Howe JP, Ockene IS, Paraskos JA. Pulmonary embolism, pulmonary hemorrhage and pulmonary infarction. N Engl J Med 1977; 296: 1431-5.
3 Stein PD, Terrin ML, Hales CA. et al. Clinical, laboratory, roentgenographic, and electrocardiographic findings in patients with acute pulmonary embolism and no pre-existing cardiac or pulmonary disease. Chest 1991; 100: 598-603.
4 The 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: 2753-9.
5 Perrier A, Bounameaux H, Morabia A. et al. Diagnosis of pulmonary embolism by a decision analysis-based strategy including clinical probability, D-dimer levels, and ultrasonography: a management study. Arch Intern Med 1996; 156: 531-6.
6 Perrier A, Desmarais S, Miron MJ. et al. Non-invasive diagnosis of venous thromboembolism in outpatients. Lancet 1999; 353: 190-5.
7 Perrier A, Miron MJ, Desmarais S. et al. Using clinical evaluation and lung scan to rule out suspected pulmonary embolism: is it a valid option in patients with normal results of lower-limb venous compression ultrasonography?. Arch Intern Med 2000; 160: 512-6.
8 Wells PS, Ginsberg JS, Anderson DR. et al. Use of a clinical model for safe management of patients with suspected pulmonary embolism. Ann Intern Med 1998; 129: 997-1005.
9 Wells PS, Anderson DR, Rodger M. et al. Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer. Thromb Haemost 2000; 83: 416-20.
10 Wicki J, Perneger T, Junod AF, Bounameaux H, Perrier A. Assessing clinical probability of pulmonary embolism in the emergency ward: a simple score. Arch Intern Med 2001; 161: 92-7.
11 Goldhaber SZ, Haire WD, Feldstein ML. et al. Alteplase versus heparin in acute pulmonary embolism: randomized trial assessing right ventricular function and pulmonary perfusion. Lancet 1993; 341: 507-11.
12 Wolfe MW, Lee RT, Feldstein ML, Parker JA, Come PC, Goldhaber SZ. Prognostic significance of right ventricular hypokinesis and perfusion lung scan defects in pulmonary embolism. Am Heart J 1994; 127: 1371-5.
13 Kasper W, Konstantinides S, Geibel A. et al. Management strategies and determinants of outcome in acute major pulmonary embolism: results of a multicenter registry. J Am Coll Cardiol 1997; 30: 1165-71.
14 Azarian R, Wartski M, Collignon MA. et al. Lung perfusion scans and hemodynamics in acute and chronic pulmonary embolism. J Nucl Med 1997; 38: 980-3.
15 Ribeiro A, Juhlin-Dannfelt A, Brodin LA, Holmgren A, Jorfeldt L. Pulmonary embolism: relation between the degree of right ventricle overload and the extent of perfusion defects. Am Heart J 1998; 135: 868-74.
16 Konstantinides S, Geibel A, Olschewski M. et al. Association between thrombolytic treatment and the prognosis of hemodynamically stable patients with major pulmonary embolism. Circulation 1997; 96: 882-8.
17 Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry. Lancet 1999; 353: 1386-9.
18 Grifoni S, Olivotto I, Cecchini P. et al. Short-term clinical outcome of patients with acute pulmonary embolism, normal blood pressure, and echo-cardiographic right ventricular dysfunction. Circulation 2000; 101: 2817-22.
19 The Urokinase in Pulmonary Embolism Trial: a national cooperative study. Circulation 1973; 47 (suppl. II): 1-108.
20 Stein PD, Goldhaber SZ, Henry JW. Alveolar-arterial oxygen gradient in the assessment of acute pulmonary embolism. Chest 1995; 107: 139-43.
21 Ransohoff DF, Feinstein AR. Problems of spectrum and bias in evaluating the efficacy of diagnostic tests. N Engl J Med 1978; 299: 926-30.
22 Perrier A, Desmarais S, Goehring C. et al. D-dimer testing for suspected pulmonary embolism in outpatients. Am J Respir Crit Care Med 1997; 156: 492-6.
23 Becker DM, Philbrick JT, Abbitt PL. Real-time ultrasonography for the diagnosis of lower extremity deep venous thrombosis: the wave of the future?. Arch Intern Med 1989; 149: 1731-4.
24 Bounameaux H, Cirafici P, de Moerloose P. et al. Measurement of D-dimer in plasma as diagnostic aid in suspected pulmonary embolism. Lancet 1991; 337: 196-200.
25 Wicki J, Perrier A, Perneger T, Bounameaux H, Junod AF. Predicting adverse outcome in patients with acute pulmonary embolism: a risk score. Thromb Haemost 2000; 84: 548-52.