Articles7 February 2006
    Author, Article, and Disclosure Information



    International guidelines include several strategies for diagnosing pulmonary embolism with confidence, but little is known about how these guidelines are implemented in routine practice.


    To evaluate the appropriateness of diagnostic management of suspected pulmonary embolism and the relationship between diagnostic criteria and outcome.


    Prospective cohort study with a 3-month follow-up.


    116 emergency departments in France and 1 in Belgium.


    1529 consecutive outpatients with suspected pulmonary embolism.


    Appropriateness of diagnostic criteria according to international guidelines; incidence of thromboembolic events during follow-up.


    Diagnostic management was inappropriate in 662 (43%) patients: 36 of 429 (8%) patients with confirmed pulmonary embolism and 626 of 1100 (57%) patients in whom pulmonary embolism was ruled out. Independent risk factors for inappropriate management were age older than 75 years (adjusted odds ratio, 2.27 [95% CI, 1.48 to 3.47]), known heart failure (odds ratio, 1.53 [CI, 1.11 to 2.12]), chronic lung disease (odds ratio, 1.39 [CI, 1.00 to 1.94]), current or recent pregnancy (odds ratio, 5.92 [CI, 1.81 to 19.30]), currently receiving anticoagulant treatment (odds ratio, 4.57 [CI, 2.51 to 8.31]), and the lack of a written diagnostic algorithm and clinical probability scoring in the emergency department (odds ratio, 2.54 [CI, 1.51 to 4.28]). Among patients who did not receive anticoagulant treatment, 44 had a thromboembolic event during follow-up: 5 of 418 (1.2%) patients who received appropriate management and 39 of 506 (7.7%) patients who received inappropriate management (absolute risk difference, 6.5 percentage points [CI, 4.0 to 9.1 percentage points]; P < 0.001). Inappropriateness was independently associated with thromboembolism occurrence (adjusted odds ratio, 4.29 [CI, 1.45 to 12.70]).


    This was an observational study without evaluation of the risk for overdiagnosis.


    Diagnostic management that does not adhere to guidelines is frequent and harmful in patients with suspected pulmonary embolism. Several risk factors for inappropriateness constitute useful findings for subsequent interventions.

    *For members of the EMDEPU Study Group, see the Appendix.


    • 1. American College of Emergency Physicians Clinical Policies CommitteeClinical policy: critical issues in the evaluation and management of adult patients presenting with suspected pulmonary embolism. Ann Emerg Med2003;41:257-70. [PMID: 12548278] CrossrefMedlineGoogle Scholar
    • 2. Barritt DWJordan SCAnticoagulant drugs in the treatment of pulmonary embolism. A controlled trial. Lancet1960;1:1309-12. [PMID: 13797091] CrossrefMedlineGoogle Scholar
    • 3. Pineda LAHathwar VSGrant BJClinical suspicion of fatal pulmonary embolism. Chest2001;120:791-5. [PMID: 11555511] CrossrefMedlineGoogle Scholar
    • 4. Linkins LAChoi PTDouketis JDClinical impact of bleeding in patients taking oral anticoagulant therapy for venous thromboembolism: a meta-analysis. Ann Intern Med2003;139:893-900. [PMID: 14644891] LinkGoogle Scholar
    • 5. Kline JAJohns KLColucciello SAIsrael EGNew diagnostic tests for pulmonary embolism. Ann Emerg Med2000;35:168-80. [PMID: 10650235] CrossrefMedlineGoogle Scholar
    • 6. Chunilal SDEikelboom JWAttia JMiniati MPanju AASimel DLet alDoes this patient have pulmonary embolism? JAMA2003;290:2849-58. [PMID: 14657070] CrossrefMedlineGoogle Scholar
    • 7. Mountain DDiagnosing pulmonary embolism: a question of too much choice? Emerg Med (Fremantle)2003;15:250-62. [PMID: 12786647] CrossrefMedlineGoogle Scholar
    • 8. Miller ACBoldy DAPulmonary embolism guidelines: will they work? [Editorial]. Thorax2003;58:463. [PMID: 12775852] CrossrefMedlineGoogle Scholar
    • 9. Cockcroft DWGault MHPrediction of creatinine clearance from serum creatinine. Nephron1976;16:31-41. [PMID: 1244564] CrossrefMedlineGoogle Scholar
    • 10. British Thoracic Society Standards of Care Committee Pulmonary Embolism Guideline Development GroupBritish Thoracic Society guidelines for the management of suspected acute pulmonary embolism. Thorax2003;58:470-83. [PMID: 12775856] CrossrefMedlineGoogle Scholar
    • 11. Kearon CDiagnosis of pulmonary embolism. CMAJ2003;168:183-94. [PMID: 12538548] MedlineGoogle Scholar
    • 12. Kruip MJLeclercq MGvan der Heul CPrins MHBuller HRDiagnostic strategies for excluding pulmonary embolism in clinical outcome studies. A systematic review. Ann Intern Med2003;138:941-51. [PMID: 12809450] LinkGoogle Scholar
    • 13. Guidelines on diagnosis and management of acute pulmonary embolism. Task Force on Pulmonary Embolism, European Society of Cardiology. Eur Heart J2000;21:1301-36. [PMID: 10952823] CrossrefMedlineGoogle Scholar
    • 14. Fedullo PFTapson VFClinical practice. The evaluation of suspected pulmonary embolism. N Engl J Med2003;349:1247-56. [PMID: 14507950] CrossrefMedlineGoogle Scholar
    • 15. Peduzzi PConcato JKemper EHolford TRFeinstein ARA simulation study of the number of events per variable in logistic regression analysis. J Clin Epidemiol1996;49:1373-9. [PMID: 8970487] CrossrefMedlineGoogle Scholar
    • 16. Stein PDTerrin MLHales CAPalevsky HISaltzman HAThompson BTet alClinical, laboratory, roentgenographic, and electrocardiographic findings in patients with acute pulmonary embolism and no preexisting cardiac or pulmonary disease. Chest1991;100:598-603. [PMID: 1909617] CrossrefMedlineGoogle Scholar
    • 17. Chagnon IBounameaux HAujesky DRoy PMGourdier ALCornuz Jet alComparison of two clinical prediction rules and implicit assessment among patients with suspected pulmonary embolism. Am J Med2002;113:269-75. [PMID: 12361811] CrossrefMedlineGoogle Scholar
    • 18. Grimshaw JMShirran LThomas RMowatt GFraser CBero Let alChanging provider behavior: an overview of systematic reviews of interventions. Med Care2001;39:II2-45. [PMID: 11583120] CrossrefMedlineGoogle Scholar
    • 19. Musset DParent FMeyer GMartre SGirard PLeroyer Cet alDiagnostic strategy for patients with suspected pulmonary embolism: a prospective multicentre outcome study. Lancet2002;360:1914-20. [PMID: 12493257] CrossrefMedlineGoogle Scholar
    • 20. Perrier ARoy PMAujesky DChagnon IHowarth NGourdier ALet alDiagnosing pulmonary embolism in outpatients with clinical assessment, d-dimer measurement, venous ultrasound, and helical computed tomography: a multicenter management study. Am J Med2004;116:291-9. [PMID: 14984813] CrossrefMedlineGoogle Scholar
    • 21. Schoepf UJGoldhaber SZCostello PSpiral computed tomography for acute pulmonary embolism. Circulation2004;109:2160-7. [PMID: 15136509] CrossrefMedlineGoogle Scholar
    • 22. Wells PSAnderson DRRodger MStiell IDreyer JFBarnes Det alExcluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer. Ann Intern Med2001;135:98-107. [PMID: 11453709] LinkGoogle Scholar
    • 23. Perrier ADesmarais SMiron MJdeMoerloose PLepage RSlosman Det alNon-invasive diagnosis of venous thromboembolism in outpatients. Lancet1999;353:190-5. [PMID: 9923874] CrossrefMedlineGoogle Scholar