Importance of risk factors for the evaluation of patients with a suspected pulmonary embolism.

The reliable exclusion of a pulmonary embolism (PE) in hemodynamically stable patients remains a challenge. The European Society of Cardiology guidelines for PE diagnosis published in 2008 and updated in 2014 recommend a low-threshold computed tomography (CT) indication for patients with a high probability of pulmonary embolism or those with elevated levels of D-dimers. Certain elements of the recommendations are controversial, while others, including the evaluation of the risk factors for PE, are considered only in individual cases. In the present study, various risk factors, including obesity, smoking, contraceptive use, immobility level, history of malignant disease and thrombophilia and the factors of familial predisposition, deep vein thrombosis (DVT)/PE-history, long-distance flying <1 week and surgery <4 weeks previously, were retrospectively examined in 492 patients with a suspected PE. The data demonstrated a significant risk of PE with contraceptive use, a history of DVT/PE and thrombophilia. The immobility level, surgery <4 weeks and long-distance flying <1 week previously, as well as family history, malignant disease, obesity and smoking, were not observed to be associated with a significantly higher risk of PE. Contraceptive use and thrombophilia, in addition to a history of DVT/PE, each appear to have a significant predictive value in the context of PE risk stratification. Therefore, patients with a suspected PE, who additionally present with at least one of the aforementioned risk factors, should undergo further diagnostic steps for PE risk stratification, including a low-threshold CT examination, even in the absence of elevated D-dimers.

Incidence of pulmonary embolism in an emergency department cohort evaluated with a simple symptom-based diagnostic algorithm.

BACKGROUND: Although complex scores were recommended for diagnosis of pulmonary embolism (PE), acceptance in clinical practice is limited. In our Emergency Department a symptom-based algorithm for patients with suspected PE including computed tomographic pulmonary angiography (CTPA) and D-dimer testing was implemented. PATIENTS AND METHODS: The cases of 492 patients presenting with either chest pain, dyspnea or syncope for whom this algorithm was applied, were retrospectively analyzed with respect to the incidence of PE, D-dimer and high-sensitive troponin levels. RESULTS: Our algorithm detected PE in 59 out of 492 patients. D-Dimer levels were significantly higher in the PE group than in the patients without PE (p<0.0001). High-sensitive troponin was significantly increased in patients with central PE compared to other patients (p<0.01). CONCLUSION: Our data demonstrate the utility and practicability of our symptom-based algorithm in combination with D-dimer testing and the use of CTPA in patients with suspected PE.