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

Tom van der Huller*, Nick van Es, Paul L. den Exter, Josien van Es, Inge C. M. Mos, Renee A. Douma, Marieke J. H. A. Kruip, Marcel M. C. Hovens, Marije ten Woldes, Mathilde Nijkeuter, Hugo ten Cate, Pieter W. Kamphuisen, Harry R. BuIler, Menno V. Huisman, Frederikus A. Klok

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

10 Citations (Web of Science)

Abstract

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.

Original languageEnglish
Pages (from-to)1622-1629
Number of pages8
JournalThrombosis and Haemostasis
Volume117
Issue number8
DOIs
Publication statusPublished - Aug 2017

Keywords

  • Pulmonary embolism
  • computed tomography
  • diagnosis
  • safety
  • DEEP-VEIN THROMBOSIS
  • D-DIMER
  • DIAGNOSIS
  • MANAGEMENT
  • CT
  • ULTRASONOGRAPHY
  • GUIDELINES
  • ALGORITHM
  • RISK

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