Pulmonary embolism is a common clinical disorder that is associated with high morbidity and mortality if untreated. In the only randomized study comparing anticoagulant therapy with no treatment in patients with pulmonary embolism, 26% of untreated patients had a fatal embolic event and another 26% developed nonfatal recurrent emboli1. With a course of anticoagulant treatment, the recurrence rate of thromboembolic events decreases to approximately 2% to 9% over 3 to 6 months2, 3. However, anticoagulation always carries a risk for bleeding (annual rate of major bleeding, 7%)4, 5. To avoid unnecessary anticoagulant therapy, it is therefore important to rapidly confirm or exclude pulmonary embolism in patients who present with suspicion of the disorder. Diagnosing or excluding pulmonary embolism on the basis of clinical manifestations alone is difficult because such manifestations are nonspecific6. Approximately 25% of patients with suspected pulmonary embolism have the disease confirmed by objective testing7-9. The goal of the first diagnostic strategies introduced was to confirm rather than exclude the presence of pulmonary emboli. The more recently evaluated diagnostic approaches have focused on identifying patients who probably do not have pulmonary embolism and therefore do not require anticoagulant therapy. Various invasive and noninvasive diagnostic methods have been advocated for excluding the disease. We performed a systematic review of the literature to evaluate diagnostic strategies designed to exclude pulmonary embolism. Our objective was to investigate whether clinical outcome evaluation properly documented the safety of withholding anticoagulant treatment in patients in whom pulmonary embolism was excluded according to a given diagnostic strategy. We assessed the accuracy of the various diagnostic strategies by examining the number of symptomatic thromboembolic events (deep venous thrombosis or pulmonary embolism) that occurred without anticoagulant treatment during a follow-up period of at least 3 months. Studies were grouped according to the number of rounds of diagnostic testing performed before pulmonary embolism was ruled out.

B. Löwenberg (Bob)
Erasmus University Rotterdam
Bayer bv Health Care Pharmaceuticals, Büller , Prof. Dr. H.R. (promotor), Glaxo Smith Kline bv, Löwenberg, Prof. Dr. B. (promotor), Novo Nordisk Farma bv, Roche Nederland bv, Wyeth Pharmaceuticals bv, ZLB Behring nv
Erasmus MC: University Medical Center Rotterdam

Kruip, M.J.H.A. (2006, December 15). Improving the diagnostic strategy of pulmonary embolism. Erasmus University Rotterdam. Retrieved from http://hdl.handle.net/1765/8175