What are the ACP guidelines for the evaluation of suspected acute pulmonary embolism (PE)?

Updated: Jun 06, 2019
  • Author: Daniel R Ouellette, MD, FCCP; Chief Editor: Zab Mosenifar, MD, FACP, FCCP  more...
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Answer

In 2015, the ACP released guidelines for the evaluation of patients with suspected acute PE, which included the following recommendations [109] :

  • Plasma D-dimer tests are more appropriate for those at intermediate risk for a PE, and no testing may be necessary for some patients at low risk.
  • Use either the Wells or Geneva rules to choose tests based on a patient's risk for PE.
  • If the patient is at low risk, clinicians should use the eight Pulmonary Embolism Rule-Out Criteria (PERC); if a patient meets all eight criteria, the risks of testing are greater than the risk for embolism, and no testing is needed.
  • For patients at intermediate risk, or for those at low risk who do not meet all of the rule-out criteria, use a high-sensitivity plasma D-dimer test as the initial test.
  • In patients older than 50 years, use an age-adjusted threshold (age × 10 ng/mL, rather than a blanket 500 ng/mL), because normal D-dimer levels increase with age.
  • Patients with a D-dimer level below the age-adjusted cutoff should not receive any imaging studies.
  • Patients with elevated D-dimer levels should then receive imaging.
  • Patients at high risk should skip the D-dimer test and proceed to CT pulmonary angiography, because a negative D-dimer test does not eliminate the need for imaging in these patients.
  • Clinicians should only obtain ventilation-perfusion scans in patients with a contraindication to CT pulmonary angiography or if CT pulmonary angiography is unavailable.
  • Clinicians should use validated clinical prediction rules to estimate pretest probability in patients in whom acute PE is being considered.

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