Diagnosis and Exclusion of Pulmonary Embolism.

BACKGROUND: Failure to test for pulmonary embolism (PE) can be a lethal mistake, but PE and produces symptoms similar to many other diseases. Overtesting for PE has negative consequences.

OBJECTIVES: Use published evidence to create a rationale and safe diagnostic approach for ambulatory and emergency patients with suspected PE in 2017.

FINDINGS: Pulmonary embolism need not be pursued in patients with no symptoms of PE in the present or recent history (dyspnea, chest pain, cough or syncope), and always normal vital signs. When clinicians have a low clinical suspicion for PE or a Wells score<2, they can reasonably exclude PE with the Pulmonary Embolism Rule out Criteria (PERC rule). For patients with a "PE-unlikely" pretest probability (Wells or simplified revised Geneva score<5), PE can be ruled out with a normal or age-adjusted D-dimer concentrations. Other patients should undergo pulmonary vascular imaging, and the choices are discussed, including computerized tomographic pulmonary angiography, planar and single-photon emission computed tomography (SPECT).

CONCLUSIONS: A thoughtful algorithm for PE exclusion and diagnosis requires pretest probability assessment in all patients, followed by selective use of clinical criteria, the quantitative D-dimer, and pulmonary vascular imaging.