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THE QUARTERLY JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING

Rivista di Medicina Nucleare e Imaging Molecolare


A Journal on Nuclear Medicine and Molecular Imaging
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Guest Editors: Pistolesi M. and Pupi A.


The Quarterly Journal of Nuclear Medicine 2001 Dicembre;45(4):287-93

lingua: Inglese

Assessing the clinical probability of pulmonary embolism

Miniati M., Pistolesi M. *

From the Institute of Clinical Physiology “Consiglio Nazionale delle Ricerche (CNR)”, Pisa, Italy
*Department of Section of Nuclear Medicine Critical Care University of Florence, Florence, Italy


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Clin­ical assess­ment is a cor­ner­stone of the ­recently val­i­dated diag­nostic strat­e­gies for pul­mo­nary embo­lism (PE). ­Although the diag­nostic ­yield of indi­vidual symp­toms, ­signs, and ­common labor­a­tory ­tests is lim­ited, the com­bi­na­tion of ­these var­i­ables, ­either by empir­ical assess­ment or by a pre­dic­tion ­rule, can be ­used to ­express a clin­ical prob­ability of PE. The ­latter may ­serve as ­pretest prob­ability to pre­dict the prob­ability of PE ­after fur­ther objec­tive ­testing (pos­te­rior or ­post-­test prob­ability). ­Over the ­last few ­years, ­attempts ­have ­been ­made to ­develop struc­tured pre­dic­tion ­models for PE. In a Cana­dian mul­ti­center pros­pec­tive ­study, the clin­ical prob­ability of PE was ­rated as low, inter­me­diate, or ­high ­according to a ­model ­which ­included assess­ment of pre­senting symp­toms and ­signs, ­risk fac­tors, and pres­ence or ­absence of an alter­na­tive diag­nosis at ­least as ­likely as PE. The prev­a­lence of PE in the low, inter­me­diate, and ­high ­pretest prob­ability cat­e­go­ries was 3, 28, and 78%, respec­tively. ­This ­model ­relies ­heavily on the ­clinician’s sub­jec­tive judge­ment as to ­whether an alter­na­tive diag­nosis is as ­likely as or ­more ­likely ­than PE, and, as ­such, it can be ­hardly stan­dard­ized. Fur­ther­more, the ­inherent com­plexity of the ­model may ­limit its appli­cability in ­daily clin­ical prac­tice. ­Recently, a ­simple clin­ical ­score was devel­oped to ­stratify out­pa­tients ­with sus­pected PE ­into ­groups ­with low, inter­me­diate, or ­high clin­ical prob­ability. ­Logistic regres­sion was ­used to pre­dict param­e­ters asso­ciated ­with PE. A ­score ≤4 iden­ti­fied ­patients ­with low prob­ability of ­whom 10% had PE. The prev­a­lence of PE in ­patients ­with inter­me­diate (­score 5-8) and ­high prob­ability (­score ≥9) was 38 and 81%, respec­tively. As ­opposed to the Cana­dian ­model, ­this clin­ical ­score is stan­dard­ized. The pre­dictor var­i­ables iden­ti­fied in the ­model, how­ever, ­were ­derived ­from a ­data ­base of emer­gency ­ward ­patients. ­This ­model may, there­fore, not be ­valid in ­assessing the clin­ical prob­ability of PE in inpa­tients. In the ­PISA-PED ­study, a clin­ical diag­nostic algo­rithm was devel­oped ­which ­rests on the iden­tifi­ca­tion of ­three rel­e­vant clin­ical symp­toms and on ­their asso­ci­a­tion ­with elec­tro­car­di­o­graphic and/or radio­graphic abnor­mal­ities spe­cific for PE. ­Among ­patients who, ­according to the ­model, had ­been ­rated as ­having a ­high clin­ical prob­ability, the prev­a­lence of ­proven PE was 97%, ­while it was 3% in ­those ­with low prob­ability. The prev­a­lence of PE in ­patients ­with inter­me­diate clin­ical prob­ability was 41%. ­These ­results under­score the impor­tance of incor­po­rating the stan­dard­ized ­reading of the elec­tro­car­di­o­gram and of the ­chest radio­graph ­into the clin­ical eval­u­a­tion of ­patients ­with sus­pected PE. The inter­pre­ta­tion of ­these labor­a­tory ­data, how­ever, ­requires expe­ri­ence. ­Future ­research is ­needed to ­develop stan­dard­ized ­models, of var­ying ­degree of com­plexity, ­which may ­find appli­ca­tion in dif­ferent clin­ical set­tings to pre­dict the prob­ability of PE.

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