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Invited Commentary |

Computed Tomographic Pulmonary Angiography to Diagnose Acute Pulmonary Embolism: The Good, the Bad, and the Ugly Comment on “The Prevalence of Clinically Relevant Incidental Findings on Chest Computed Tomographic Angiograms Ordered to Diagnose Pulmonary Embolism”

Ami Schattner, MD
Arch Intern Med. 2009;169(21):1966-1968. doi:10.1001/archinternmed.2009.400.
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Pulmonary embolism (PE) remains a frequent and potentially fatal diagnosis that is easily missed. Its highly variable and nonspecific presentation mandates both a high index of suspicion and dependence on imaging techniques to confirm and treat PE or rule out the diagnosis.

With the advent of recent technological advances, multidetector computed tomographic pulmonary angiography (CTA) has rapidly become the sine qua non for the workup of PE. No wonder. The 1-minute test, ability to directly visualize clots within the pulmonary arteries, good sensitivity, and widespread availability 24 hours a day form indeed an impressive combination. When all of this is added to the allure of any new, sophisticated, and powerful technology, most suspected cases of acute PE are being currently referred for CTA soon after presentation.1 However, this decision may not be as straightforward as it seems.

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Suggested simple algorithm to substantially reduce the use of computed tomographic pulmonary angiography (CTA) in suspected cases of pulmonary embolism (PE). The numbered boxes indicate the sequence of actions by which subsets of patients can be sequentially ruled out or confirmed as having PE; DVT, deep vein thrombosis; V/Q, ventilation/perfusion. To convert D-dimer to nanomoles per liter, multiply by 5.476. *Patient numbers are approximate, based on large, high-quality studies cited; †technological improvement in scanning techniques are under way and results of trials might further improve diagnostic accuracy and reduce the number of indeterminate scans (none of 87 single photon emission computed tomographic [SPECT] V/Q scans was nondiagnostic)9,11; ‡unless contraindicated; §gadolinium-enhanced magnetic resonance angiography, digital subtraction angiography, SPECT V/Q scintigraphy, and others.

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