Diagnosing pulmonary embolism: a question of too much choice?

The diagnosis of pulmonary embolism (PE) is difficult with many patients treated without the disease or left untreated without an adequate diagnostic work up. Recent advances in PE diagnosis are reviewed. The use of risk stratification in PE diagnosis is strongly recommended and evidence on how it can best be performed summarized. The Ginsberg/Wells stratification rule is recommended currently as the best validated rule. Computed tomographic pulmonary angiography (CTPA) was found to have quite poor sensitivity and to be poorly validated. It is recommended as adequate as a positive test in moderate/high risk groups and an exclusionary test in low risk groups or where an adequate alternative diagnosis is found. For D-Dimer tests the only test with adequate sensitivity and validation in management studies is the VIDASCopyright D-Dimer. This is in low/intermediate risk groups in the ED population. The Simpli-RedCopyright test is also reviewed but is too insensitive for most populations. Echocardiography: this is good in compromised patients as it is a bedside test which when negative virtually excludes PE. If positive in the right setting it has a high positive predictive value. A negative echocardiogram predicts a benign clinical course for PE. The rest of the paper details the authors approach to integrating these new techniques with established algorithms and where progress is likely to occur in the next few years. These include improvements in CTPA (plus the addition of CT venography), new point of care D-Dimer tests, better risk stratification rules and integration of new strategies with artificial neural networks or computerized guidelines.