This is the current release of the guideline.

This release of the guideline represents a revision of a 1995 American College of Emergency Physicians chest pain policy (American College of Emergency Physicians. Clinical policy for the initial approach to adults presenting with a chief complaint of chest pain, with no history of trauma. Ann Emerg Med 1995;25:274-299) as it relates to the initial approach to patients with signs and symptoms of pulmonary embolism.

Definitions for the strength of evidence (Class I-III) and strength of recommendations (Level A-C) are repeated at the end of the Major Recommendations.

1. Can a negative D-dimer exclude pulmonary embolism (PE)?

   Level A recommendations. None specified.

   Level B recommendations. In patients with a low pretest probability of PE, use the following tests to exclude PE:

   1. A negative quantitative D-dimer assay (turbidimetric or enzyme-linked immunosorbent assay [ELISA]).
   2. A negative whole blood cell qualitative D-dimer assay in conjunction with a Wells’ score of 2 or less.

   Level C recommendations. In patients with a low pretest probability of PE, negative findings on a whole blood D-dimer assay (when not used with Wells’ scoring system) or immunofiltration D-dimer assay can be used to exclude PE.

2. When can ventilation-perfusion (V/Q) scan alone or in combination with venous ultrasonography and/or D-dimer assay exclude PE?

   Level A recommendations. In patients with a low-to-moderate pretest probability of PE, a normal perfusion scan reliably excludes clinically significant PE.

   Level B recommendations. In patients with a low-to-moderate pretest probability of PE and a non-diagnostic V/Q scan, use 1 of the following tests instead of pulmonary arteriogram to exclude clinically significant PE:

   1. A negative quantitative D-dimer assay (turbidimetric or ELISA).
   2. A negative whole blood cell qualitative D-dimer assay in conjunction with a Wells’ score of 4 or less.
   3. A negative single bilateral venous ultrasonographic scan for low-probability patients.
   4. A negative serial* bilateral venous ultrasonographic scan for moderate-probability patients (*serial venous ultrasonography refers to scheduling a patient for follow-up examination in the emergency department within 3 to 7 days or referring to a primary care physician for follow-up).

   Level C recommendations. In patients with a low-to-moderate pretest probability of PE and a nondiagnostic V/Q scan, use a negative whole blood D-dimer assay (when not used with Wells’ scoring system) or immunofiltration D-dimer assay to exclude PE.

3. Can spiral computed tomography (CT) replace V/Q scanning in the diagnostic evaluation of PE?

   Level A recommendations. None specified.

   Level B recommendations. Thin collimation spiral CT scan of the thorax with 1- to 2-mm image reconstruction may be used as an alternative to V/Q scan during the diagnostic evaluation of patients with suspected PE.

   Level C recommendations. Spiral CT scan of the thorax with delayed CT venography may be used for increased detection of patients with significant thromboembolic disease.

4. What are the indications for fibrinolytic therapy in patients with PE?

   Level A recommendations. None specified.

   Level B recommendations. Consider fibrinolytic therapy in hemodynamically unstable patients with confirmed PE.

   Level C recommendations. Consider fibrinolytic therapy in:

   1. Hemodynamically stable patients with confirmed PE and right ventricular (RV) dysfunction on echocardiography.
   2. Unstable patients with high clinical index of suspicion (especially if RV dysfunction can be demonstrated on bedside echocardiography).

Definitions:

Strength of Evidence

Literature Classification Schema*

Design/Class 1

• Therapy^#: Randomized, controlled trials or meta-analyses of randomized controlled trials
• Diagnosis^&: Prospective cohort using a criterion standard
• Prognosis**: Population prospective cohort

Design/Class 2

• Therapy^#: Nonrandomized trial
• Diagnosis^&: Retrospective observational
• Prognosis**: Retrospective cohort, case control

Design/Class 3

• Therapy^#: Case series, case report, other (e.g., consensus, review)
• Diagnosis^&: Case series, case report, other (e.g., consensus, review)
• Prognosis**: Case series, case report, other (e.g., consensus, review)

*Some designs (e.g., surveys) will not fit this schema and should be assessed individually.

^#Objective is to measure therapeutic efficacy comparing >2 interventions.

^&Objective is to determine the sensitivity and specificity of diagnostic tests.

**Objective is to predict outcome including mortality and morbidity.

Strength of Recommendations

Level A recommendations. Generally accepted principles for patient management that reflect a high degree of clinical certainty (i.e., based on "strength of evidence class I" or overwhelming evidence from "strength of evidence class II" studies that directly address all the issues).

Level B recommendations. Recommendations for patient management that may identify a particular strategy or range of management strategies that reflect moderate clinical certainty (i.e., based on "strength of evidence class II" studies that directly address the issue, decision analysis that directly addresses the issue, or strong consensus of "strength of evidence class III" studies).

Level C recommendations. Other strategies for patient management based on preliminary, inconclusive, or conflicting evidence or, in the absence of any published literature, based on panel consensus.

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Not applicable: The guideline was not adapted from another source.

2003 Feb

American College of Emergency Physicians - Medical Specialty Society

American College of Emergency Physicians

American College of Emergency Physicians (ACEP) Clinical Policies Subcommittee on Suspected Pulmonary Embolism

ACEP Clinical Policies Committee

Members of the Clinical Policies Subcommittee on Suspected Pulmonary Embolism: Francis M. Fesmire, MD (Chair); Jeffrey A. Kline, MD; Stephen J. Wolf, MD

Members of the Clinical Policies Committee: William C. Dalsey, MD (Chair 2000-2002, Co-Chair 2002-2003); Andy S. Jagoda, MD (Co-Chair 2002-2003); Wyatt W. Decker, MD; Francis M. Fesmire, MD; Steven A. Godwin, MD; John M. Howell, MD; J. Stephen Huff, MD; Edwin K. Kuffner, MD; Thomas W. Lukens, MD, PhD; Benjamin E. Marett, RN, MSN, CEN, CNA, COHN-S (Emergency Nurses Association [ENA] Representative 2002); Thomas P. Martin, MD; Jessie Moore, RN, MSN, CEN (ENA Representative 2001); Barbara A. Murphy, MD; Devorah Nazarian, MD; Scott M. Silvers, MD; Bonnie Simmons, DO; Edward P. Sloan, MD, MPH; Robert L. Wears, MD, MS; Stephen J. Wolf, MD (Emergency Medicine Residents’ Association Representative 2001-2002); Robert E. Suter, DO, MHA (Board Liaison 2000-2001); Susan M. Nedza, MD (Board Liaison 2001-2003); Rhonda Whitson, RHIA, Staff Liaison, Clinical Policies Committee and Subcommittees

Not stated

This is the current release of the guideline.

This release of the guideline represents a revision of a 1995 American College of Emergency Physicians chest pain policy (American College of Emergency Physicians. Clinical policy for the initial approach to adults presenting with a chief complaint of chest pain, with no history of trauma. Ann Emerg Med 1995;25:274-299) as it relates to the initial approach to patients with signs and symptoms of pulmonary embolism.

None available

None available

This NGC summary was completed by ECRI on June 5, 2003. The information was verified by the guideline developer on July 18, 2003.