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ARTICLE

Single-Detector Helical Computed Tomography as the Primary Diagnostic Test in Suspected Pulmonary Embolism: A Multicenter Clinical Management Study of 510 Patients

Marco J.L. van Strijen, MD; Wouter de Monyé, MD; Jan Schiereck, MD; Gerard J. Kieft, MD; Martin H. Prins, MD; Menno V. Huisman, MD; Peter M.T. Pattynama, MD, for the Advances in New Technologies Evaluating the Localisation of Pulmonary Embolism (ANTELOPE) Study Group*

18 February 2003 | Volume 138 Issue 4 | Pages 307-314

Background: Helical computed tomography (CT) is a readily available tool for diagnosing pulmonary embolism (PE); however, its role in the management of patients with clinically suspected PE has not been fully established.

Objective: To determine the effectiveness and safety of using helical CT of the pulmonary arteries as the primary diagnostic test in patients with suspected PE.

Design: Multicenter, prospective clinical outcome study.

Setting: Two academic hospitals and one large teaching hospital in the Netherlands.

Patients: 510 consecutive inpatients and outpatients with clinically suspected PE followed for 3 months.

Interventions: Patients underwent helical CT of the pulmonary arteries within 24 hours after presenting with signs and symptoms of PE. If CT results were normal or inconclusive, compression ultrasonography was performed on the same day as CT and repeated on days 4 and 7 if findings on the first compression ultrasonography were normal. When CT or compression ultrasonography results were positive for thromboembolism, anticoagulation was started. Anticoagulation was not started when results of CT were negative for PE or indicated an alternative diagnosis that explained the clinical signs and symptoms, or when results on serial compression ultrasonography were normal.

Measurements: Patients received instructions to report any symptoms or signs of PE or deep venous thrombosis (DVT) during the 3-month follow-up period. The authors performed compression ultrasonography or phlebography for suspected DVT and pulmonary angiography for suspected PE.

Results: Computed tomography identified PE in 124 of 510 patients (24.3%) and an alternative diagnosis in 130 patients (25.5%); CT scans were normal in 248 patients (48.6%). The CT scan could not be interpreted in 8 patients (1.6%) and was not obtained in 2. Compression ultrasonography revealed DVT in 2 patients at the first examination; findings on repeated compression ultrasonography at days 4 and 7 were normal. Mortality in the patients with normal helical CT scans was 4.1% (10 of 246 patients). No patients in this group died of fatal PE, 1 patient developed nonfatal PE, and venous thromboembolism occurred in 0.4% of these patients (95% CI, 0% to 2.2%). In the patients with alternative diagnoses, 1 patient had DVT on objective testing during follow-up. Mortality in this group was 21.5% (28 of 130 patients); in 1 of these patients, PE could not be confidently ruled out as a contributing cause of death. Venous thromboembolism occurred in 1.5% of these patients (CI, 0.2% to 5.6%).

Conclusions: In patients with suspected PE, helical CT can be used safely as the primary diagnostic test to rule out PE. Serial compression ultrasonography has limited additional value.

*For a list of the Advances in New Technologies Evaluating the Localisation of Pulmonary Embolism (ANTELOPE) Study Group, see the Appendix.

Editors' Notes Context One strategy for diagnosing pulmonary embolism is helical computed tomography (CT) of the pulmonary arteries followed by compression ultrasonography of the leg veins if the CT scan shows no embolism and no clear alternative diagnosis. Contribution This prospective study of 510 patients with clinically suspected pulmonary embolism found that one third of the CT scans that were negative for emboli identified alternative diagnoses. Only 2 of the 248 patients with negative CT scans and no alternative diagnoses had positive results on venous compression ultrasonography. 376 patients had no evidence of emboli on CT scans and did not receive anticoagulant therapy; 2 had documented thromboembolism during 3 months of follow-up. Implications Helical CT alone misses few clinically important pulmonary embolisms. –The Editors

 

Author and Article Information

From Leyenburg Ziekenhuis, The Hague; Leiden University Medical Center, Leiden; Utrecht Medical Center, Utrecht; and Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands.

Acknowledgments: The results of this study are part of the results of the ANTELOPE Study Group (Advances in New Technologies Evaluating the Localisation of Pulmonary Embolism), a Dutch prospective multicenter trial on pulmonary embolism. The authors thank Annette van den Berg-Huijsmans, Gerda Labadie, and Ria Koolma for their help with the statistical analysis of the results and management of the data.

Grant Support: By grant D94-090 from the Dutch National Health Insurance Council (Ziekenfondsraad).

Requests for Single Reprints: Menno V. Huisman, MD, Department of General Internal Medicine, Room B3Q-84, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, the Netherlands; e-mail, m.v.huisman{at}lumc.nl.

Current Author Addresses: Drs. van Strijen and Kieft: Department of Radiology, Leyenburg Ziekenhuis, Leyweg 275, 2545 CH The Hague, the Netherlands.

Dr. Monye': Department of Radiology, Leiden University Medical Cen-ter, PO Box 9600, 2300 RC Leiden, the Netherlands.

Dr. Schiereck: Department of Radiology, Utrecht Medical Center, Utre-cht, PO Box 85500, 3508 GA Utrecht, the Netherlands.

Dr. Prins: Department of Epidemiology, Academic Hospital Maastricht, PO Box 616, 6200 MD Maastricht, the Netherlands.

Dr. Huisman: Department of General Internal Medicine, Room B3Q-84, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, the Netherlands.

Dr. Pattynama: Department of Radiology, Erasmus Medical Center Rot-terdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands.

Author Contributions: Conception and design: M.J.L. van Strijen, G.J. Kieft, M.H. Prins, M.V. Huisman, P.M.T. Pattynama.

Analysis and interpretation of the data: M.J.L. van Strijen, M.H. Prins, M.V. Huisman.

Drafting of the article: M.J.L. van Strijen, M.V. Huisman, P.M.T. Pat-tynama. Critical revision of the article for important intellectual content: M.J.L. van Strijen, W. de Monye', G.J. Kieft, M.H. Prins, M.V. Huisman, P.M.T. Pattynama.

Final approval of the article: M.J.L. van Strijen, W. de Monye', J. Schiereck, G.J. Kieft, M.H. Prins, M.V. Huisman, P.M.T. Pattynama.

Provision of study materials or patients: M.J.L. van Strijen, W. de Monye', J. Schiereck, M.H. Prins, M.V. Huisman.

Statistical expertise: M.H. Prins.

Obtaining of funding: G.J. Kieft, M.H. Prins, P.M.T. Pattynama.

Administrative, technical, or logistic support: P.M.T. Pattynama. Collection and assembly of data: M.J.L. van Strijen, W. de Monye', J. Schiereck.

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