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patients with PE compared with those without embolism; the presence and magnitude of the elevation are not useful in diagnosis, but correlate with adverse outcomes, including death, mechanical ventilation and prolonged hospitalization
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probability of PE, the diagnosis was confirmed in only 4% Such patients may reasonably be observed off therapy without angiography All other patients with nondiagnostic V/ Q scans require further testing to determine the presence of venous thromboembolism 3 CT Helical CT pulmonary angiography has essentially supplanted V/Q scanning as the initial diagnostic study in the United States for suspected PE Helical CT pulmonary angiography requires administration of intravenous radiocontrast dye but is otherwise noninvasive A high quality study is very sensitive for the detection of thrombus in the proximal pulmonary arteries but less so in more distal arteries where it may miss as many as 75% of subsegmental defects, compared with pulmonary angiography Compar ing helical CT pulmonary angiography to the V/Q scan as the initial test for PE, detection of thrombi is roughly comparable, although more alternative pulmonary diagnoses are made with CT scanning Test characteristics of helical CT pulmonary angiography vary widely by study and facility Factors influencing results include patient size and cooperation, the type and quality of the scanner, the imaging protocol, and the experience of the interpreting radiologist Early studies comparing singledetector helical CT with standard angiography reported sensitivity of 53 60% and specificity of 81 97% for the diagnosis of PE The 2006 PIOPED II study, using multidetector (four-row) helical CT and excluding the 6% of patients whose studies were inconclusive, reported sensitivity of 83% and specificity of 96% A 15 20% false-negative rate is high for a screening test, and raises the practical question whether it is safe to withhold anticoagulation in patients with a negative helical CT Research data provide two complementary answers The insight of PIOPED I, that the clinical assessment of pretest probability improves the performance of the V/Q scan, was confirmed with helical CT pulmonary angiography in PIOPED II, where positive and negative predictive values were highest in patients with concordant clinical assessments but poor with conflicting assessments: The negative predictive value of a normal helical CT in patients with a high pretest probability was only 60% Therefore, a normal helical CT alone does not exclude PE in high-risk patients, and either empiric therapy or further testing is indicated A large, prospective trial called the Christopher Study incorporated objective, validated pretest clinical assessment into diagnostic algorithms using D-dimer measurement In this study, patients with a high pretest probability and a negative helical CT pulmonary angiogram who were not receiving anticoagulation had a low (< 2%) 3-month incidence of subsequent PE This low rate of complications supports the contention that many false-negative studies represent clinically insignificant, small distal thrombi and provides support for monitoring most patients with a high-quality negative helical CT pulmonary angiogram off therapy (see Integrated Approach to Diagnosis of Pulmonary Embolism below) The rate of false-positive helical CT pulmonary angiograms and overtreatment of PE has not been as well studied to date
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1 Chest radiography The chest radiograph is necessary to exclude other common lung diseases and to permit interpretation of the ventilation-perfusion (V/ Q) scan, but it does not establish the diagnosis by itself The chest radiograph was normal in only 12% of patients with confirmed PE in the PIOPED I study The most frequent findings were atelectasis, parenchymal infiltrates, and pleural effusions However, the prevalence of these findings was the same in hospitalized patients without PE A prominent central pulmonary artery with local oligemia (Westermark s sign) or pleural-based areas of increased opacity that represent intraparenchymal hemorrhage (Hampton s hump) are uncommon Paradoxically, the chest radiograph may be most helpful when normal in the setting of hypoxemia 2 Lung scanning A perfusion scan is performed by injecting radiolabeled microaggregated albumin into the venous system, allowing the particles to embolize to the pulmonary capillary bed To perform a ventilation scan, the patient breathes a radioactive gas or aerosol while the distribution of radioactivity in the lungs is recorded A defect on perfusion scanning represents diminished blood flow to that region of the lung This finding is not specific for PE Defects in the perfusion scan are interpreted in conjunction with the ventilation scan to give a high, low, or intermediate (indeterminate) probability that PE is the cause of the abnormalities Criteria for the combined interpretation of ventilation and perfusion scans (commonly referred to as a single test, the V/ Q scan) are complex, confusing, and not completely standardized A normal perfusion scan excludes the diagnosis of clinically significant PE (negative predictive value of 91% in the PIOPED I study) A high-probability V/ Q scan is most often defined as having two or more segmental perfusion defects in the presence of normal ventilation and is sufficient to make the diagnosis of PE in most instances (positive predictive value of 88% among PIOPED I patients) V/ Q scans are most helpful when they are either normal or indicate a high probability of PE Such readings are reliable interobserver agreement is best for normal and high-probability scans and they carry predictive power: The likelihood ratios associated with normal and highprobability scans are 010 and 18, respectively, indicating significant and frequently conclusive changes from pretest to posttest probability However, 75% of PIOPED I V/ Q scans were nondiagnostic, ie, of low or intermediate probability At angiography, these patients had an overall incidence of PE of 14% and 30%, respectively One of the most important findings of PIOPED I was that the clinical assessment of pretest probability could be used to aid the interpretation of the V/ Q scan For patients with low probability V/ Q scans and a low (20% or less) clinical pretest
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