What are the ACEP guidelines for the diagnosis of 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 contrast, the 2011 guidelines of the American College of Emergency Physicians (ACEP) find that either objective criteria or gestalt clinical assessment can be used to risk-stratify patients with suspected PE. There is insufficient evidence to support the preferential use of one method over another (level B). For patients with a low pretest probability for suspected PE, PERC may be used to exclude the diagnosis based on historical and physical examination data alone (level B). Other key recommendations include the following [110] :

  • Negative quantitative D-dimer assay results can be used to exclude PE in patients with a low pretest probability for PE (level A).
  • Negative quantitative D-dimer assay results may be used to exclude PE in patients with an intermediate pretest probability for PE (level C).
  • For patients with a low or PE unlikely (Wells score 4) pretest probability for PE who require additional diagnostic testing (eg, positive D-dimer result, or highly sensitive D-dimer test not available), a negative, multidetector CT pulmonary angiogram alone can be used to exclude PE (level B).
  • For patients with an intermediate or high pretest probability for PE and a negative CT pulmonary angiogram result in whom a clinical concern for PE still exists and CT venogram has not already been performed, consider additional diagnostic testing (eg, D-dimer, lower extremity imaging, VQ scanning, traditional pulmonary arteriography) prior to exclusion of VTE disease (level C).
  • Venous ultrasound may be considered as initial imaging in patients with obvious signs of deep venous thrombosis (DVT) for whom venous ultrasound is readily available, patients with relative contraindications for CT scan (eg, borderline renal insufficiency, CT contrast agent allergy), and pregnant patients. A positive finding in a patient with symptoms consistent with PE can be considered evidence for diagnosis of VTE disease and may preclude the need for additional diagnostic imaging in the emergency department (level B).

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