New recommendations for the diagnosis of Pulmonary Embolism

Diagnosis of Pulmonary Embolism (PE) is a challenging process. Because PE is only present in about one-third of those in whom it is suspected, the diagnosis must be confirmed or excluded by further testing. In an article in the December issue of The American Journal of Medicine, researchers describe the diagnostic pathways that can be used to achieve an accurate and safe diagnosis of PE.

Based on the results from the Prospective Investigation of Pulmonary Embolism Diagnosis II (PIOPED II) and other studies, these guidelines include both evidence-based recommendations and opinions based on information available at this time.

Writing in the article, Paul D. Stein, MD, states "[we] recommend stratification of all patients with suspected pulmonary embolism according to an objective probability assessment. A negative D-dimer rapid ELISA with a low or moderate probability clinical assessment can safely exclude pulmonary embolism. If pulmonary embolism is not excluded, CT angiography/CT venography is recommended by most PIOPED II investigators, although CT angiography alone is an option. In patients with discordant findings on clinical assessment and CT imaging, further evaluation depends on clinical judgment. In pregnant women and women of reproductive age, ventilation/perfusion scans are recommended by many PIOPED II investigators as the first imaging test."

In an accompanying commentary, James E. Dalen, MD, MPH, describes how various techniques for the diagnosis of PE have been introduced over the last 40 years, each with advantages and disadvantages in accuracy, risk to the patient and cost. Writing about the article, he states, "These recommendations from the PIOPED investigators will have a major impact on the diagnosis and treatment of pulmonary embolism."

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The study is "Diagnostic Pathways in Acute Pulmonary Embolism: Recommendations of The PIOPED II Investigators" by Paul D. Stein, MD, Pamela K. Woodard, MD, John G. Weg, MD, Thomas W. Wakefield, MD, Victor F. Tapson, MD, H. Dirk Sostman, MD, Thomas A. Sos, MD, Deborah A. Quinn, MD, Kenneth V. Leeper, Jr, MD, Russell D. Hull, MBBS, MSc, Charles A. Hales, MD, Alexander Gottschalk, MD, Lawrence R. Goodman, MD, Sarah E. Fowler, PhD, and John D. Buckley, MD, MPH. The commentary is "Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED I, II, and III) and the Diagnosis of Pulmonary Embolism" by James E. Dalen, MD, MPH. These appear in The American Journal of Medicine, Volume 119, Issue 12 (December 2006), published by Elsevier.


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