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ACP: Risk stratification should guide imaging, testing for suspected PE
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The American College of Physicians today released a policy paper that outlines the best practice advice for physicians evaluating patients with a suspected acute pulmonary embolism.
The paper suggests that physicians should stratify patients into groups for whom different diagnostic strategies are appropriate.
“The use of computed tomography (CT) for the evaluation of patients with suspected pulmonary embolism is increasing despite no evidence that this increased use has led to improved patient outcomes, while exposing patients to unnecessary risks and expense,” Wayne J. Riley, MD, MPH, MBA, MACP, president of the American College of Physicians (ACP) and adjunct professor of healthcare management at Vanderbilt University, said in a press release. “ACP’s advice is designed to help physicians identify patients for whom a pulmonary embolism is so unlikely that they need no further testing, for whom plasma D-dimer testing can provide additional risk stratification, and for whom imaging is indicated because of their high risk and clinical presentation.”
The ACP’s clinical guidelines committee sought to provide advice on this topic because it is difficult to diagnose PE and, as a result, testing has risen drastically. The ACP’s concern was that some tests might be overused — including CT and plasma D-dimer — that could lead to patient harm and great expenses without a mortality benefit.
The policy paper included a 6-step protocol for physicians to follow when they suspect PE:
- Use a validated clinical prediction rule to estimate the pretest probability of PE to standardize the evaluation for those physicians who may not encounter or evaluate PE often.
- Clinicians should not request imaging or obtain D-dimer measurements for patients with a low pretest PE probability who meet all PE rule-out criteria (PERC).
- High sensitivity D-dimer measurements should be obtained for patients with an intermediate pretest probability of PE or in patients with a low pretest probability who do not meet all PERC. Clinicians should not use imaging in this population.
- Physicians should use age-adjusted D-dimer thresholds — or age multiplied by 10 ng/mL as opposed to the standard 500 ng/mL — for patients aged older than 50 years to determine if imaging is warranted because normal D-dimer levels increase with age.
- Clinicians should not order imaging in any patient with a D-dimer level below the age-adjusted cutoff.
- Imaging with CT pulmonary angiography (CTPA) should be obtained for patients with high pretest probability of PE; however, the use of ventilation-perfusion scans should be limited to patients contraindicated for a CTPA or when a CTPA is unavailable.
“While highly sensitive, plasma D-dimer testing is nonspecific and false-positives can lead to unnecessary imaging,” Ali S. Raja, MD, MBA, a member of the ACP’s clinical guidelines committee, vice chair of the department of emergency medicine at Massachusetts General Hospital and associate professor of emergency medicine at Harvard Medical School, said in the release. “The use of an age-adjusted threshold resulted in maintenance of sensitivities with improved specificities in all age groups.”
The ACP noted that their policy papers are only meant as guidelines that may not apply to every patient in all situations and that they should not override clinician judgement. Further, all policy papers expire after 5 years, unless they are updated before then. – by Anthony SanFilippo
Disclosure: Riley and Raja report no relevant financial disclosures. Please see the full study for a list of all other committee member disclosures.
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