Warning from ACP About Overuse of Imaging for Patients with Suspected Pulmonary Embolism

The American College of Physicians (ACP; Philadelphia, PA, USA) has warned that the overuse of Computed Tomography (CT), and D-dimer testing, for suspected Pulmonary Embolism (PE) cases could harm patients and create unnecessary costs, without improving the patient outcome.

The ACP suggests that physicians stratify patients with suspected PE, to help them decide on the optimal diagnostic strategy. The ACP published the new clinical guidelines in a policy paper in the September 29, 2015, online issue of the journal Annals of Internal Medicine. According to the ACP physicians should group PE patients according to different possible diagnostic strategies.

PE is usually caused by a deep vein thrombosis in the leg that breaks loose unexpectedly and is carried by blood vessels into the lungs. Physicians increasingly use CT scans to evaluate suspected PE patients, even for patients with a low pre-test probability of PE. Instead, the ACP suggests that physicians use the Pulmonary Embolism Rule-Out Criteria (PERC). Patients that meet all eight PERC criteria, and have a low pre-test chance of PE should not undergo D-dimer testing or CT imaging. Patients with an intermediate pre-test chance of PE, or those with a low pre-test chance of PE, and that do not meet all PERC criteria should initially undergo a high-sensitivity D-dimer test only. Only those patients with high pre-test chance of PE should undergo CT Pulmonary Angiography (CTPA) and imaging.

When CTPA is not possible or contraindicated physicians should use a ventilation/perfusion lung scan (V/Q scan). According to the ACP patients with a high pre-test probability of PE do not need a D-dimer measurement.

According to the ACP there are risks and expense associated with the use of CT imaging for suspected PE cases, and there is no evidence showing that CT improves the outcomes for such patients.

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