A Fast Track Strategy for Managing Suspected Pulmonary Embolism (PE) in Outpatients

Abstract number: P1661

Sandset¹ PM, Ghanima² W, Almaas² V, Aballi² S, Dörje² C, Nielssen³ B, Holmen³ LO

¹¹Department of Hematology, Ullevål University Hospital, Oslo, Norway ²²Department of Internal Medicine, Østfold Hospital, Fredrikstad, Norway ³³Department of Radiology, Østfold Hospital, Fredrikstad, Norway

Aims:  A prospective outcome study designed to evaluate a simple strategy for managing outpatients for suspected pulmonary embolism (PE), based on D-dimer, and multi-slice computed tomography (MSCT).

Methods:  495 consecutive patients referred to the Emergency Department at Østfold Hospital Fredrikstad, Norway, for suspected PE were considered for inclusion. 63 (12.7%) patients were excluded. The final cohort consisted of 432 patients. Patients were managed by sequential non-invasive testing starting with D-Dimer test. Normal D-Dimer (Liatest, Stago, cut-off value <=0.4 mg/L) was used to rule out PE in patients with low-intermediate clinical probability (CP). Patients with normal D-Dimer, but with high CP, and patients with elevated D-Dimer proceeded to MSCT (4-row detector CT scan). If MSCT diagnosis was inconclusive, bilateral compression ultrasonography was recommended followed by a perfusion scan and eventually pulmonary angiography. The entire cohort was followed-up for 3 months.

Results:  Normal D-dimer and low-intermediate CP ruled out PE in 103 patients (24% [95% CI 20.1–28.4]). 17 patients had normal D-dimer but high CP and proceeded to MSCT. All proved negative for PE. 329 patients underwent MSCT examination. PE was diagnosed in 94 patients (22%) and was ruled out by negative MSCT in 221 patients. MSCT scans were inconclusive in 14 (4%) patients. No patients developed objectively verified venous thromboembolism (VTE) during the 3-month follow-up period. However, the cause of death was adjudicated as possibly related to PE in two patients, resulting in an overall 3-month thromboembolic risk of 0.6% (95% CI 0–2.2%). The diagnostic algorithm yielded a definite diagnosis in 97% of the patients.

Conclusions:  This simple and non-invasive strategy, combing D-dimer and MSCT for the management of outpatients with suspected PE appears to be safe and effective.