Refining our approach to pulmonary embolism

From the February 27 issue of Archives of Internal Medicine come three studies and an editorial on this subject.

A prediction rule using history, physical exam and arterial oxygen saturation identified PE patients at low risk. Echocardiographic assessment of right ventricular function was not required. This is appealing because the safety of initial out patient treatment of PE is not clear. The authors caution that validation of the rule in additional studies is necessary before it can be recommended as a clinical tool to select patients for out patient treatment.

In this study of emergency room patients with prior history of venous thromboembolism a negative D-dimer test (VIDAS D-Dimer Exclusion) seemed to safely exclude a recurrent event. The relatively low number of patients with prior thrombosis who have a negative D-dimer limits the applicability of this approach.

Multimodal bedside testing was as good as V/Q scanning in ruling out PE in this study. A negative clinical score combined with a negative D-dimer safely excluded PE. If these two modalities were discordant, bedside determination of alveolar dead space fraction excluded some additional patients.

It was all nicely synthesized in this accompanying editorial.