Excluding the Diagnosis of Pulmonary Embolism: Is There a Magic Ball? COPYRIGHT © 2015, ALL RIGHTS RESERVED From the Publishers of

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Guys: I am in our observation unit and I need some sage advice to settle a disagreement. I just saw a 48-year-old woman who was admitted last night with left pleuritic chest pain. She has had 5 days of URI symptoms with hacking nonproductive cough. Her medical history is unremarkable and she has no history of VTE or PE, no recent surgery or immobilization, no hemoptysis. She has no history of cancer. Exam: Afebrile BP 130/70 HR 90 bpm Lungs clear with scattered wheeze. Cardiac rhythm regular Heart sounds normal (no murmur) Extremity exam is normal O2 sat 95% CXR: clear lung fields So hear is the rub: I am concerned about the pleuritic nature of the chest pain. While my suspicion is that her symptoms are due to a viral upper respiratory tract infection I think that she needs a CT pulmonary angiogram to be as sure as possible that she doesn’t have a pulmonary embolus. My partner says no, a high sensitivity D-Dimer should be done and only if that is elevated should a CT pulmonary angiogram be done. Our resident says that no test is necessary because the likelihood of this being a pulmonary embolus is low. Can you guys direct us on this one? Guys: I am in our observation unit and I need some sage advice to settle a disagreement. I just saw a 48-year-old woman who was admitted last night with left pleuritic chest pain. She has had 5 days of URI symptoms with hacking nonproductive cough. Her medical history is unremarkable and she has no history of VTE or PE, no recent surgery or immobilization, no hemoptysis. She has no history of cancer. Exam: Afebrile BP 130/70 HR 90 bpm Lungs clear with scattered wheeze. Cardiac rhythm regular Heart sounds normal (no murmur) Extremity exam is normal O2 sat 95% CXR: clear lung fields So hear is the rub: I am concerned about the pleuritic nature of the chest pain. While my suspicion is that her symptoms are due to a viral upper respiratory tract infection I think that she needs a CT pulmonary angiogram to be as sure as possible that she doesn’t have a pulmonary embolus. My partner says no, a high sensitivity D-Dimer should be done and only if that is elevated should a CT pulmonary angiogram be done. Our resident says that no test is necessary because the likelihood of this being a pulmonary embolus is low. Can you guys direct us on this one? Copyright © 2015

Patient 48-year-old woman URI, cough, pleuritic chest pain No history of VTE or PE No recent travel, immobilization, surgery No history of cancer Copyright © 2015

Very low: No further testing needed Low to Intermediate: D-dimer helps with the risk stratification High likelihood: Proceed to imaging (CT Pulmonary Angiogram) Probability of Pulmonary Embolism Copyright © 2015

Why Not CT Scan Everyone? Copyright © 2015 Increased use has not led to improved patient outcome With increased use in ED leading to increased detection there has been no reduction in mortality Radiation exposure Cost

* Evaluation of Patients With Suspected Acute Pulmonary Embolism: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians Ann Intern Med. 2015;163(9): doi: /M Our patient = 0: Low risk Copyright © 2015

Evaluation of Patients With Suspected Acute Pulmonary Embolism: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians Ann Intern Med. 2015;163(9): doi: /M Our patient = 0: Low risk Copyright © 2015

Evaluation of Patients With Suspected Acute Pulmonary Embolism: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians Ann Intern Med. 2015;163(9): doi: /M Copyright © 2015

Evaluation of Patients With Suspected Acute Pulmonary Embolism: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians Ann Intern Med. 2015;163(9): doi: /M Pathway for the evaluation of patients with suspected PE. PE = pulmonary embolism; PERC = Pulmonary Embolism Rule-Out Criteria. * Using either a clinical decision tool or gestalt. Figure Legend: Copyright © 2015

Pearls Use validated clinical prediction rules to estimate pretest probability Do not obtain D-dimer measurements or imaging studies in patients with a low pretest probability of PE and who meet all PERC 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 a low pretest probability of PE who do not meet all PERC Copyright © 2015

Pearls Do not use imaging tests as the initial test in patients who have a low or intermediate pretest probability of PE When a D-dimer is indicated age adjust it in patients older than 50 (top normal = age x 10ng/ml) Do not obtain an imaging study in patients with a D-dimer below the age adjusted cut off Do not obtain D-dimer in patients with a high probability of PE Obtain a CT Pulmonary angiogram in patients with high probability PE Reserve V/Q scans for high pretest probability patients who have contraindications to CTPA or if CTPA is indicated but not available Copyright © 2015

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