DIAGNOSIS OF

PULMONARY
EMBOLUS

Adapted from source

INTRODUCTION
No single non invasive test is both sensitive and specific
enough
Test: “ruling in” PE, e.g. helical CT or “ruling out” e.g.
D-dimer, others do both, often non-diagnostic e.g. VQ
scans
Choice of initial diagnostic test guided by clinical
assessment of probability & patient characteristics that
may influence test accuracy
Clinical assessment alone unreliable, objective testing
crucial
Failure to Dx PE high mortality, incorrect Dx of PE
exposes patient risks of anticoagulation.
 OBJECTIVES OF THIS
REVIEW
Outline approach to Dx of PE that minimises the
use of Pulmonary Angiography (PA)
Based on 2 guiding principles
Accurate test/combination of tests should have a
positive predictive value 85% & a negative
predictive value of 95% OR
Be associated with no more than 2% VTE
during F/U if it is the basis of withholding
treatment
 CLINICAL ASSESSMENT
2 Categories of clinical assessment
◦ Empirical clinical assessment: Hx,
Examination, CXR, ECG, ABG – low,
intermediate & high probability categories
 PIOPED & McMaster studies, prevalence of PE
established by PA was 15%, 38%, 79%
◦ Standardized clinical model (or prediction
rules):
 Wells & colleagues used S&S, alternative Dx
possible & presence of risk factors for VTE- low,
intermediate & high probability categories
 CLINICAL ASSESSMENT
Wells Score
◦ Variable Points
 S&S of DVT 3.0
 Alternative Dx less likely than PE 3.0
 HR>100 b/min 1.5
 Immobilization/Sx past 4/52 1.5
 Previous DVT/PE 1.5
 Haemoptysis 1.0
 Malignancy(on Rx/in past 6/12) 1.0
◦ High >6, Moderate 2-6, Low <2
Clinical assessment SUMMARY
Wells scoring, prevalence of PE 2% low
probability group, 19% intermediate & 50% in
high probability group
Evidence shows that clinical assessment

( empirical/standardised) can stratify patients’

probability of having PE
Prevalence expected: <10% low probability,
20% intermediate group & >60% high
probability category
 NATURAL HX OF VTE
 Most cases DVT (~90%) start in the calf
 Isolated calf DVT rarely causes leg symptoms or PE
 25% unRxd calf DVT will extend to proximal veins, do so
within a week of presentation
 75% of pts with PE have DVT
 Most pts with symptomatic PE have incr D-dimer
 ~50% symptomatic PE involve lobar or main pulmonary arteries
 Without Rx,1/2 pts symptomatic DVT/PE have recurrence
within 3/12
 With Rx of PE, ~50% resolution of perfusion defects in 2-4/52.
Complete resolution occur in 2/3 of pts
 With Rx of proximal DVT, residual thrombus is seen on USS in
½ of pts at 1 yr
 D-DIMER TESTING
D-dimer – cross-linked fibrin lysed by plasmin
Elevations are non-specific: infection, inflammation,
ageing, cancer, cardiac ischemia
Wide variety of assays
Valid assays for PE Dx: 2 Categories
◦ Very Highly sensitive D-dimer test
 Sensitivity >98%; Usu low specificity ~40%- high false
positives
 Used to rule out PE
◦ Moderate-Highly sensitive D-dimer test
 Sensitivity 85-98%, not high enough to rule out PE, needs to be
combined with another assessment
◦ HBH: Simple D-dimer assay: 100% sensitive, ~50%
specific
OTHER DIAGNOSTIC TESTS
VQ SCAN
◦ Normal scan excludes PE
◦ Perfusion defects are non-specific-1/3 pts with defects
have PE
◦ Probability increases with increase in number and size of
perfusion defects & presence of normal ventilation scan
CT
◦ Spiral/Helical scans with contrast (CT-PA)
MRI
Tests
for DVT: USS, Venography: indirect way of
Dx PE
OTHER DIAGNOSTIC TESTS
Pulmonary Angiography: Requires more
expertise & support staff; invasive, time
consuming, more expensive, and less available
Echocardiography: Transthoracic/TEE
◦ directly visualise thrombi in right heart
chamber or central pulmonary arteries
◦ show right heart hemodynamic changes that
indirectly suggest PE
◦ TEE visualise thrombi in central pulmonary
arteries with a specificity of >90%
 DX OF PE IN PREGNANCY
MODIFICATIONS IN MXM
◦ 1ST: USS of proximal veins – initial test
◦ 2nd : Amount of radio-isotope used for VQS
reduced & duration of scanning extended
◦ 3rd: If PA performed, brachial approach used
with abdominal screening
◦ 4th: In the absence of safety data, helical CT is
discouraged
CLINICAL SITUATIONS ALTER
DIAGNOSTIC APPROACH/ TEST
INTERPRETATION
In-hospital patients
Inpatients, especially after surgery, often
have increased D-dimer levels that
markedly reduce the value of D-dimer
testing (e.g., specificity of 7% in
inpatients versus 47% in outpatients).
Treatment of presumptive
pulmonary embolism
D-dimer levels are estimated to decrease
about 25% after 24 hours of heparin
therapy, and this is expected to reduce the
sensitivity of D-dimer testing (e.g., from
96% to 89%)
High clinical probability
◦ D-dimer testing has little clinical utility in patients
with a high clinical probability of pulmonary
embolism, because specificity is lower in this group
(e.g., 28% compared with 54% with low clinical
probability)
◦ The combination of a lower specificity and high
prevalence of embolism results in a low frequency of
negative D-dimer results (e.g., 17% compared with
51% with low probability), which have a lower
negative predictive value(e.g., 77% compared with
100% with low probability).
Previous venous thrombo-embolism
◦ Imaging abnormalities associated with previous
DVT or PE may persist and be misdiagnosed as
recurrent VTE(e.g., decrease in positive predictive
value of a high probability lung scan from 91% to
74% with a history of PE).
◦ In about half of patients with recently diagnosed
DVT who present with suspected PE and have a
high-probability lung scan, the abnormalities
predate the onset of chest symptoms
Influence of age on accuracy of
diagnostic tests
◦ The specificity of D-dimer testing and lung
scanning decreases with age (e.g., D-dimer
specificity: 67% at ≤ 50 years versus 10% at ≥
80 years
◦ Proportion of lung scans that are non-
diagnostic: 32% at ≤ 40 years versus 58% at ≥
80 years)
Cardiopulmonary disease
Cardiopulmonary disease (particularly
lung disease) is associated with a high
proportion of non-diagnostic lung scans
(e.g., 78% [91% with COPD] versus 64%)
and a lower positive predictive value with
a high-probability defect (e.g., 83%
versus 93%)
Malignant disease
Malignancy reduces the specificity of
many tests for PE(e.g., D-dimer: 48%
versus 82%) & may also result in false-
positive results (e.g., high-probability
lung scans or abnormal helical CT with
intra-thoracic malignancy).
Central venous catheters
The arms and central veins should be
considered as a source for emboli & as a
target for diagnostic testing in patients
with central venous catheters who are
suspected of having PE
Pregnancy
As compared with non-pregnant patients,
the prevalence of PE among pregnant
patients who are investigated for PE is
low (about 5% versus about 20%) and the
prevalence of normal perfusion scans is
high (about 70% versus about 25%)
 SUMMARY
PE IS CONFIRMED BY:
◦ Pulmonary angiography: intra-luminal filling
defect
◦ Helical CT: intra-luminal filling defect in a
lobar or main pulmonary artery
◦ Ventilation–perfusion scan: high-probability
scan and moderate/high clinical probability
◦ Diagnostic tests for DVT: evidence of acute
DVT with non-diagnostic ventilation–
perfusion scan or helical CT
 SUMMARY
PE IS EXCLUDED BY:
◦ Pulmonary angiogram: normal
◦ Perfusion scan: normal
◦ D-dimer test: normal test with a very high sensitivity(≥ 98%)
& at least moderate specificity (≥ 40%)
◦ Normal D-dimer that has at least moderately high sensitivity
(≥ 85%) and specificity (≥ 70%) AND
 (a) low clinical suspicion for PE OR
 (b) normal alveolar dead space fraction
◦ Non-diagnostic VQS or normal helical CT, and normal
proximal venous ultrasound scans AND
 (a) low clinical suspicion for PE OR
 (b) normal D-dimer test that has at least moderately high sensitivity (≥
85%) and specificity (≥ 70%)
QUESTIONS
 TAKE HOME MESSAGE
 When individual tests are non-
diagnostic, it is possible to
combine their results to confirm
or exclude pulmonary embolism
Assessment of clinical
probability is of vital importance