ACP issues best practice advice on evaluating suspected PE
The goal was to provide practical, evidence-based advice for clinicians evaluating adult inpatients and outpatients in whom acute PE is suspected.
Physicians evaluating patients for acute pulmonary embolism (PE) should first establish pretest probability by using such measures as the Wells and Geneva rules, along with physician gestalt and the Pulmonary Embolism Rule-Out Criteria (PERC), according to recent advice from ACP.
Members of ACP's Clinical Guidelines Committee performed a literature search from 1966 to 2014 for English-language clinical trials and meta-analyses on diagnostic strategies, decision rules, laboratory tests, and imaging studies for diagnosing PE. A formal systematic review of the evidence was not performed; instead, the goal was to provide practical, evidence-based advice for clinicians evaluating adult inpatients and outpatients in whom acute PE is suspected.
The following principles of best practice advice were developed:
- 1. Clinicians should use validated clinical prediction rules to estimate pretest probability in patients in whom acute PE is being considered.
- 2. Clinicians should not obtain D-dimer measurements or imaging studies in patients who have a low pretest probability of PE and meet all PERC.
- 3. 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 PERC. Clinicians should not use imaging studies as the initial test in patients who have a low or intermediate pretest probability of PE.
- 4. 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.
- 5. Clinicians should not obtain any imaging studies in patients with a D-dimer level below the age-adjusted cutoff.
- 6. 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 for instances when CTPA is not available. Clinicians should not obtain a D-dimer measurement in patients with a high pretest probability of PE.
The guidance was published online Sept. 29 by Annals of Internal Medicine.