CTPA is preferred when VQ scan is not feasible.The strategy assumes that test results are obtained under optimal conditions. In studies using reference standards of negative venography (for DVT) or pulmonary angiography (for PE), the observed VTE rate is 2%.Modern diagnostic techniques have evolved such that current CT scanners are able to detect PE at a subsegmental level and ultrasound capable of detecting DVT within calf veins. Minor inconsistency for specificity noted but judged to be insufficient to downgrade the certainty in evidence.Certainty in evidence downgraded for indirectness because of lack of data on the accuracy of this test following a previous test in a pathway. Certainty in evidence was downgraded for serious unexplained inconsistency in specificity, with a range from 10.9% to 81.8%.Minor inconsistency for sensitivity and specificity noted but judged to be insufficient to downgrade the certainty in evidence.For patients presenting to an emergency department with a low probability of PE, PERC may be used to determine whether D-dimer testing is warranted.Validated clinical decision rules were used to assess clinical probability of PE in studies evaluating different diagnostic strategies for patients suspected of having a first episode PE. Suboptimal D-dimer or ultrasound results may require repeat testing.If clinical suspicion remains high following a negative initial ultrasound, serial ultrasound could be considered.If prior imaging is available, comparison of the previous and current imaging is warranted to determine whether the findings are new and represent recurrent PE. 2000 Feb;35(2):121-5. doi: 10.1016/s0196-0644(00)70130-2.Thromb Haemost. A decision to start with D-dimer assumes the results will be obtained in a timely manner and that the cost of D-dimer screening is offset by avoiding unnecessary VQ or CTPA for patients at low PTP for PE. A negative D-dimer rules out DVT and no additional testing or anticoagulation is required. Age-adjusted cutoff = age (years) 10 g/L (using D-dimer assays with a cutoff of 500 g/L).VQ scan is preferred over CTPA as the subsequent test to limit radiation exposure for patients likely to have a diagnostic scan, and in centers where VQ scans are available with expertise to interpret the results in a timely manner. There are limited data on the utility of D-dimer for patients receiving anticoagulant therapy who present with suspected recurrent DVT.The strategy assumes that test results are obtained under optimal conditions. Search for other works by this author on:
Framing the question and deciding on important outcomesGRADE guidelines: 1. Epub 2020 Jul 9.Giorgi-Pierfranceschi M, Paoletti O, Pan A, De Gennaro F, Nardecchia AL, Morandini R, Dellanoce C, Lombi S, Tala M, Cancelli V, Zambelli S, Bosio G, Romanini L, Testa S.Intern Emerg Med. Studies are ongoing of newer modalities such as MRI direct thrombus imaging to assess for acute or chronic thrombus.We included a total of 9 studies and 752 patients to inform estimates of test accuracy (Summary of results of studies informing sensitivity and specificity of tests for diagnosis of upper extremity DVTCertainty in evidence not downgraded for risk of bias, although few studies had a combination of reference standards that were judged to be acceptable by a panel of clinical experts.Certainty in evidence was downgraded for indirectness in instances where this test was not the index test in a diagnostic pathway.
Part D describes new interests disclosed by individuals after appointment.ASH policy required that panel members with a current, direct financial interest in a commercial entity with any product that could be affected by the guidelines be recused from making judgments about relevant recommendations.None of the researchers who contributed to the systematic evidence reviews or who supported the guideline development process had any current, material interest in a commercial entity with any product that could be affected by the guidelines. Pulmonary angiography: Criterion standard for diagnosing pulmonary embolism when MDCTA is not available Chest radiography: Normal in most cases of pulmonary embolism, but Suboptimal D-dimer or CTPA results may require repeat testing or an alternate strategy. D-dimer has limited utility in hospitalized patients and in certain patient populations (postsurgical, pregnant) due to the high frequency of positive D-dimer results with standard thresholds.Use of an age-adjusted D-dimer cutoff in outpatients older than 50 years is as safe as the standard cutoff and increases the diagnostic utility of the test.