Pulmonary Embolism (Haemodynamically Stable)
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This pathway provides a diagnostic imaging algorithm for adult patients with suspected pulmonary embolism and who are haemodynamically stable.
Date reviewed: June 2017
Date of next review: August 2023
Published: February 2018
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SYMBOL | RRL | EFFECTIVE DOSE RANGE | |
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None | 0 | |
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Minimal | < 1 millisieverts | |
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Low | 1-5 mSv | |
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Medium | 5-10 mSv | |
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High | >10 mSv |
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Teaching Points
Teaching Points
- Prior to imaging, one must clinically calculate the probability of PE. This is based on the validated 'Wells Criteria'. Other criteria which have shown good pre-test probabilities are the Revised Geneva Score and Pulmonary Embolism Rule-out Criteria (PERC)
- Chest radiograph in suspected pulmonary embolism (PE) is to exclude other causes that may mimic PE and to guide further investigations
- Patients who are at low probability for PE should have a D-Dimer. A negative D-Dimer in a low probability case of suspected PE rules out the diagnosis and no further investigation is indicated
- Patients with moderate to high pre-test probability of PE should have further imaging
- The choice of imaging is reliant on a 'normal' chest radiograph and whether the patient has a history of a chronic underlying lung disease
- Patients with a normal chest radiograph and no history of lung disease should proceed to radionuclide scan
- Patients with an abnormal chest radiograph or history of lung disease should proceed to CTPA
References
References
Date of literature search: July 2017
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
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- Raja AS, Greenberg JO, Qaseem A, Denberg TD, Fitterman N, Schuur JD. 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):701-11. (Guidelines). View the reference
- Lee CH, Hankey GJ, Ho WK, Eikelboom JW. Venous thromboembolism: diagnosis and management of pulmonary embolism. Med J Aust. 2005;182(11):569-74. (Review article). View the reference
- Freyburger G, Trillaud H, Labrouche S, Gauthier P, Javorschi S, Bernard P, et al. D-dimer strategy in thrombosis exclusion--a gold standard study in 100 patients suspected of deep venous thrombosis or pulmonary embolism: 8 DD methods compared. Thromb Haemost. 1998;79(1):32-7. (Level II evidence). View the reference
- Stein PD, Hull RD, Patel KC, Olson RE, Ghali WA, Brant R, et al. D-dimer for the exclusion of acute venous thrombosis and pulmonary embolism: a systematic review. Ann Intern Med. 2004;140(8):589-602. (Level I evidence). View the reference
- Roy PM, Colombet I, Durieux P, Chatellier G, Sors H, Meyer G. Systematic review and meta-analysis of strategies for the diagnosis of suspected pulmonary embolism. Bmj. 2005;331(7511):259. (Level I evidence). View the reference
- Carrier M, Righini M, Djurabi RK, Huisman MV, Perrier A, Wells PS, et al. VIDAS D-dimer in combination with clinical pre-test probability to rule out pulmonary embolism. A systematic review of management outcome studies. Thromb Haemost. 2009;101(5):886-92. (Level I evidence). View the reference
- Agnelli G, Becattini C. Acute pulmonary embolism. N Engl J Med. 2010;363(3):266-74. (Review article). View the reference
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- Wells PS, Ginsberg JS, Anderson DR, Kearon C, Gent M, Turpie AG, et al. Use of a clinical model for safe management of patients with suspected pulmonary embolism. Ann Intern Med. 1998;129(12):997-1005. (Level II evidence). View the reference
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- Ruggiero A, Screaton NJ. Imaging of acute and chronic thromboembolic disease: state of the art. Clin Radiol. 2017;72(5):375-88. (Review article). View the reference
- Remy-Jardin M, Pistolesi M, Goodman LR, Gefter WB, Gottschalk A, Mayo JR, et al. Management of suspected acute pulmonary embolism in the era of CT angiography: a statement from the Fleischner Society Radiology. 2007;245(2):315-29. (Review article). View the reference
- Hull RD, Raskob GE, Coates G, Panju AA. Clinical validity of a normal perfusion lung scan in patients with suspected pulmonary embolism. Chest. 1990;97(1):23-6. (Level II evidence). View the reference
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- Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED). Jama. 1990;263(20):2753-9. (Level II evidence). View the reference
- He J, Fang W, Lv B, He JG, Xiong CM, Liu ZH, et al. Diagnosis of chronic thromboembolic pulmonary hypertension: comparison of ventilation/perfusion scanning and multidetector computed tomography pulmonary angiography with pulmonary angiography. Nucl Med Commun. 2012;33(5):459-63. (Level II evidence). View the reference
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- Schoepf UJ, Holzknecht N, Helmberger TK, Crispin A, Hong C, Becker CR, et al. Subsegmental pulmonary emboli: improved detection with thin-collimation multi-detector row spiral CT. Radiology. 2002;222(2):483-90. (Level IV evidence). View the reference
- Schoepf UJ, Costello P. CT angiography for diagnosis of pulmonary embolism: state of the art. Radiology. 2004;230(2):329-37. (Review article). View the reference
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- Remy-Jardin M, Tillie-Leblond I, Szapiro D, Ghaye B, Cotte L, Mastora I, et al. CT angiography of pulmonary embolism in patients with underlying respiratory disease: impact of multislice CT on image quality and negative predictive value. Eur Radiol. 2002;12(8):1971-8. (Level IV evidence). View the reference
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- Stein PD, Fowler SE, Goodman LR, Gottschalk A, Hales CA, Hull RD, et al. Multidetector computed tomography for acute pulmonary embolism. N Engl J Med. 2006;354(22):2317-27. (Level II evidence). View the reference
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