Heightened clinical suspicion of pulmonary embolism and disregard of the D-dimer assay- a contemporary trend in an era of increased access to CT Pulmonary Angiogram?

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Heightened clinical suspicion of pulmonary embolism and disregard of the D-dimer assay- a contemporary trend in an era of increased access to CT Pulmonary Angiogram?

Intern Med J. 2013 Jun 26;

Authors: Sud R, Langfield J, Chu G

Abstract
AIM: This study compares the diagnostic approach to pulmonary embolism (PE) in the study institution to well established guidelines. The study also re-examines the cost-benefit analyses of qualitative d-dimers and lung scans in the low Wells pre-test probability (PTP) group.
DESIGN: A retrospective study of 169 consecutive CTPAs requested in the Emergency Department of a major teaching hospital during a 12 month period.
RESULTS: The prevalence of PE was 0% (0/65), 11.7% (9/77), and 0% (0/2) in the low, moderate and high PTP groups respectively, and 6.3% (9/144) overall. PTP was only documented in 10 (6.9%) cases, and the qualitative D-dimer assay was only ordered in 33.8% (22/65) of low Wells PTP subjects. The false positive d-dimer rate was 90.2% (37/41). Cost-benefit analysis and assay performance defines a narrow range of low PTP PE prevalence between 1%-5% for the utilisation of the qualitative d-dimer assay.
CONCLUSIONS: The overall prevalence of PE in subjects undergoing CTPA was significantly lower compared to data in the literature. The authors recommend warranted clinical suspicion of PE should be confirmed by a senior physician prior to placing a patient in the PE work-up pathway. In such patients, the qualitative d-dimer assay should be utilised if PTP is low, and the exclusionary efficiency of the d-dimer will be improved in the setting of higher PE prevalence in this subgroup. Hospitals should audit local PE prevalence, as cost-benefit analyses raises questions about the effectiveness of d-dimers when PE prevalence is very low in the low PTP subgroup.

PMID: 23800111 [PubMed - as supplied by publisher]

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