Multidetector Computed Tomography for Acute Pulmonary Embolism
Paul D. Stein, M.D., Sarah E. Fowler, Ph.D., Lawrence R. Goodman, M.D., Alexander Gottschalk, M.D., Charles A. Hales, M.D., Russell D. Hull, M.B., B.S., M.Sc., Kenneth V. Leeper, Jr., M.D., John Popovich, Jr., M.D., Deborah A. Quinn, M.D., Thomas A. Sos, M.D., H. Dirk Sostman, M.D., Victor F. Tapson, M.D., Thomas W. Wakefield, M.D., John G. Weg, M.D., Pamela K. Woodard, M.D., for the PIOPED II Investigators
Background The accuracy of multidetector computed tomographicangiography (CTA) for the diagnosis of acute pulmonary embolismhas not been determined conclusively.
Methods The Prospective Investigation of Pulmonary EmbolismDiagnosis II trial was a prospective, multicenter investigationof the accuracy of multidetector CTA alone and combined withvenous-phase imaging (CTA–CTV) for the diagnosis of acutepulmonary embolism. We used a composite reference test to confirmor rule out the diagnosis of pulmonary embolism.
Results Among 824 patients with a reference diagnosis and acompleted CT study, CTA was inconclusive in 51 because of poorimage quality. Excluding such inconclusive studies, the sensitivityof CTA was 83 percent and the specificity was 96 percent. Positivepredictive values were 96 percent with a concordantly high orlow probability on clinical assessment, 92 percent with an intermediateprobability on clinical assessment, and nondiagnostic if clinicalprobability was discordant. CTA–CTV was inconclusive in87 of 824 patients because the image quality of either CTA orCTV was poor. The sensitivity of CTA–CTV for pulmonaryembolism was 90 percent, and specificity was 95 percent. CTA–CTVwas also nondiagnostic with a discordant clinical probability.
Conclusions In patients with suspected pulmonary embolism, multidetectorCTA–CTV has a higher diagnostic sensitivity than doesCTA alone, with similar specificity. The predictive value ofeither CTA or CTA–CTV is high with a concordant clinicalassessment, but additional testing is necessary when the clinicalprobability is inconsistent with the imaging results.
Source Information
From the Department of Research, St. Joseph Mercy Oakland Hospital, Pontiac, Mich., and the Department of Medicine, Wayne State University, Detroit (P.D.S.); the Biostatistics Center, Department of Epidemiology and Biostatistics, George Washington University, Rockville, Md. (S.E.F.); the Department of Radiology, Medical College of Wisconsin, Milwaukee (L.R.G.); the Department of Radiology, Michigan State University, East Lansing (A.G.); the Department of Medicine, Massachusetts General Hospital, and Harvard Medical School — both in Boston (C.A.H., D.A.Q.); the Department of Medicine, University of Calgary, Calgary, Alta., Canada (R.D.H.); the Department of Medicine, Emory University, Atlanta (K.V.L.); the Department of Medicine, Henry Ford Hospital, Detroit (J.P.); the Department of Radiology, Weill Cornell Medical College, New York (T.A.S.); Weill Cornell Medical College and Methodist Hospital, Houston (H.D.S.); the Department of Medicine, Duke University, Durham, N.C. (V.F.T.); the Departments of Surgery (T.W.W.) and Medicine (J.G.W.), University of Michigan, Ann Arbor; and the Department of Radiology, Washington University, St. Louis (P.K.W.).
Address reprint requests to Dr. Stein at St. Joseph Mercy Oakland Hospital, 44405 Woodward Ave., Pontiac, MI 48341, or at steinp{at}trinity-health.org.
Hall, W. B., Truitt, S. G., Scheunemann, L. P., Shah, S. A., Rivera, M. P., Parker, L. A., Carson, S. S.
(2009). The Prevalence of Clinically Relevant Incidental Findings on Chest Computed Tomographic Angiograms Ordered to Diagnose Pulmonary Embolism. Arch Intern Med
169: 1961-1965
[Abstract][Full Text]
Schattner, A.
(2009). 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". Arch Intern Med
169: 1966-1968
[Full Text]
Bastarrika, G., Lee, Y. S., Huda, W., Ruzsics, B., Costello, P., Schoepf, U. J.
(2009). CT of Coronary Artery Disease. Radiology
253: 317-338
[Abstract][Full Text]
Bhargavan, M., Sunshine, J. H., Hervey, S. L., Jha, S., Vializ, J., Owen, J. B.
(2009). The Actual Role of CT and Ventilation-Perfusion Scanning in Workup for Suspected Pulmonary Embolism: Evidence From Hospitals. Am. J. Roentgenol.
193: 1324-1332
[Abstract][Full Text]
Sanchez, O., Planquette, B., Meyer, G.
(2009). Update on acute pulmonary embolism. ERR
18: 137-147
[Full Text]
Lee, E. Y., Kritsaneepaiboon, S., Zurakowski, D., Arellano, C. M. R., Strauss, K. J., Boiselle, P. M.
(2009). Beyond the Pulmonary Arteries: Alternative Diagnoses in Children With MDCT Pulmonary Angiography Negative for Pulmonary Embolism. Am. J. Roentgenol.
193: 888-894
[Abstract][Full Text]
Bastarrika, G., Thilo, C., Headden, G. F., Zwerner, P. L., Costello, P., Schoepf, U. J.
(2009). Cardiac CT in the Assessment of Acute Chest Pain in the Emergency Department. Am. J. Roentgenol.
193: 397-409
[Abstract][Full Text]
Hoffmann, U., Bamberg, F.
(2009). Is Computed Tomography Coronary Angiography the Most Accurate and Effective Noninvasive Imaging Tool to Evaluate Patients With Acute Chest Pain in the Emergency Department?: CT Coronary Angiography Is the Most Accurate and Effective Noninvasive Imaging Tool for Evaluating Patients Presenting With Chest Pain to the Emergency Department. Circ Cardiovasc Imaging
2: 251-263
[Full Text]
Kritsaneepaiboon, S., Lee, E. Y., Zurakowski, D., Strauss, K. J., Boiselle, P. M.
(2009). MDCT Pulmonary Angiography Evaluation of Pulmonary Embolism in Children. Am. J. Roentgenol.
192: 1246-1252
[Abstract][Full Text]
Pahade, J. K., Litmanovich, D., Pedrosa, I., Romero, J., Bankier, A. A., Boiselle, P. M.
(2009). Quality Initiatives@;DELIM@;Continuing Medical Education: Imaging Pregnant Patients with Suspected Pulmonary Embolism: What the Radiologist Needs to Know1. RadioGraphics
29: 639-654
[Abstract][Full Text]
Piazza, G., Rosenbaum, E. J., Pendergast, W., Jacobson, J. O., Pendleton, R. C., McLaren, G. D., Elliott, C. G., Stevens, S. M., Patton, W. F., Dabbagh, O., Paterno, M. D., Catapane, E., Li, Z., Goldhaber, S. Z.
(2009). Physician Alerts to Prevent Symptomatic Venous Thromboembolism in Hospitalized Patients. Circulation
119: 2196-2201
[Abstract][Full Text]
Pahade, J. K., Litmanovich, D., Pedrosa, I., Romero, J., Bankier, A. A., Boiselle, P. M.
(2009). Quality Initiatives: Imaging Pregnant Patients with Suspected Pulmonary Embolism: What the Radiologist Needs to Know. RadioGraphics
0: 293085226-
[Abstract][Full Text]
Adam, S. S., Key, N. S., Greenberg, C. S.
(2009). D-dimer antigen: current concepts and future prospects. Blood
113: 2878-2887
[Abstract][Full Text]
Nazaroglu, H., Ozmen, C. A., Akay, H. O., Kilinc, I., Bilici, A.
(2009). 64-MDCT Pulmonary Angiography and CT Venography in the Diagnosis of Thromboembolic Disease. Am. J. Roentgenol.
192: 654-661
[Abstract][Full Text]
Goodman, L. R., Sostman, H. D., Stein, P. D., Woodard, P. K.
(2009). CT Venography: A Necessary Adjunct to CT Pulmonary Angiography or a Waste of Time, Money, and Radiation?. Radiology
250: 327-330
[Full Text]
Moores, L. K.
(2009). Pulmonary Vascular Diseases. ACCP Pulmonary Med Brd Rev
25: 21-38
[Full Text]
Dellinger, R. P.
(2009). Venous Thromboembolic Disease. ACCP Crit Care Med Brd Rev
20: 197-212
[Full Text]
Konstantinides, S. V
(2008). Acute pulmonary embolism revisited. Postgrad. Med. J.
84: 651-658
[Full Text]
Reinartz, P.
(2008). To PIOPED, or Not to PIOPED. JNM
49: 1739-1740
[Full Text]
Sostman, H. D., Miniati, M., Gottschalk, A., Matta, F., Stein, P. D., Pistolesi, M.
(2008). Sensitivity and Specificity of Perfusion Scintigraphy Combined with Chest Radiography for Acute Pulmonary Embolism in PIOPED II. JNM
49: 1741-1748
[Abstract][Full Text]
Merrell, R. T., Mueller, P. S.
(2008). 54-Year-Old Man With Shortness of Breath, Confusion, and Thrombocytopenia. Mayo Clin Proc.
83: 1271-1274
[Full Text]
Piazza, G., Goldhaber, S. Z.
(2008). Pulmonary Embolism in Heart Failure. Circulation
118: 1598-1601
[Full Text]
Gibson, N. S., Sohne, M., Gerdes, V. E. A., Nijkeuter, M., Buller, H. R.
(2008). The Importance of Clinical Probability Assessment in Interpreting a Normal d-Dimer in Patients With Suspected Pulmonary Embolism. Chest
134: 789-793
[Abstract][Full Text]
Authors/Task Force Members, , Torbicki, A., Perrier, A., Konstantinides, S., Agnelli, G., Galie, N., Pruszczyk, P., Bengel, F., Brady, A. J.B., Ferreira, D., Janssens, U., Klepetko, W., Mayer, E., Remy-Jardin, M., Bassand, J.-P., ESC Committee for Practice Guidelines (CPG), , Vahanian, A., Camm, J., De Caterina, R., Dean, V., Dickstein, K., Filippatos, G., Funck-Brentano, C., Hellemans, I., Kristensen, S. D., McGregor, K., Sechtem, U., Silber, S., Tendera, M., Widimsky, P., Zamorano, J. L., Document Reviewers, , Zamorano, J.-L., Andreotti, F., Ascherman, M., Athanassopoulos, G., De Sutter, J., Fitzmaurice, D., Forster, T., Heras, M., Jondeau, G., Kjeldsen, K., Knuuti, J., Lang, I., Lenzen, M., Lopez-Sendon, J., Nihoyannopoulos, P., Perez Isla, L., Schwehr, U., Torraca, L., Vachiery, J.-L.
(2008). Guidelines on the diagnosis and management of acute pulmonary embolism: The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J
29: 2276-2315
[Full Text]
Pipavath, S. N. J., Godwin, J. D.
(2008). Acute Pulmonary Thromboembolism: A Historical Perspective. Am. J. Roentgenol.
191: 639-641
[Full Text]
Miniati, M., Bottai, M., Monti, S., Salvadori, M., Serasini, L., Passera, M.
(2008). Simple and Accurate Prediction of the Clinical Probability of Pulmonary Embolism. Am. J. Respir. Crit. Care Med.
178: 290-294
[Abstract][Full Text]
Haydar, A. A, Morgan-Hughes, G., Roobottom, C.
(2008). Investigating severe interscapular pain. BMJ
337: a688-a688
[Full Text]
Wuyts, W. A., Thomeer, M., Dupont, L. J., Verleden, G. M.
(2008). An Algorithm to Tackle Acute Exacerbations in Idiopathic Pulmonary Fibrosis. Am. J. Respir. Crit. Care Med.
177: 1397-1397
[Full Text]
Konstantinides, S. V
(2008). Acute pulmonary embolism revisited. Heart
94: 795-802
[Full Text]
King, V., Vaze, A. A., Moskowitz, C. S., Smith, L. J., Ginsberg, M. S.
(2008). D-Dimer Assay to Exclude Pulmonary Embolism in High-Risk Oncologic Population: Correlation with CT Pulmonary Angiography in an Urgent Care Setting. Radiology
247: 854-861
[Abstract][Full Text]
Mir, M. A.
(2008). Excluding Pulmonary Embolism With Computed Tomographic Pulmonary Angiography or Ventilation-Perfusion Lung Scanning. JAMA
299: 1664-1664
[Full Text]
Anderson, D. R., Rodger, M. A., Wells, P. S.
(2008). Excluding Pulmonary Embolism With Computed Tomographic Pulmonary Angiography or Ventilation-Perfusion Lung Scanning--Reply. JAMA
299: 1664-1665
[Full Text]
Tapson, V. F.
(2008). Acute Pulmonary Embolism. NEJM
358: 1037-1052
[Full Text]
Moll, S.
(2008). A Clinical Perspective of Venous Thromboembolism. Arterioscler. Thromb. Vasc. Bio.
28: 373-379
[Full Text]
Link, R. P.
(2008). National Heart, Lung, and Blood Institute Programs for Deep Vein Thrombosis. Arterioscler. Thromb. Vasc. Bio.
28: 392-393
[Full Text]
Sostman, H. D., Stein, P. D., Gottschalk, A., Matta, F., Hull, R., Goodman, L.
(2008). Acute Pulmonary Embolism: Sensitivity and Specificity of Ventilation-Perfusion Scintigraphy in PIOPED II Study. Radiology
246: 941-946
[Abstract][Full Text]
Hunsaker, A. R., Zou, K. H., Poh, A. C., Trotman-Dickenson, B., Jacobson, F. L., Gill, R. R., Goldhaber, S. Z.
(2008). Routine Pelvic and Lower Extremity CT Venography in Patients Undergoing Pulmonary CT Angiography. Am. J. Roentgenol.
190: 322-326
[Abstract][Full Text]
Kalva, S. P., Jagannathan, J. P., Hahn, P. F., Wicky, S. T.
(2008). Venous Thromboembolism: Indirect CT Venography during CT Pulmonary Angiography--Should the Pelvis Be Imaged?. Radiology
246: 605-611
[Abstract][Full Text]
Roach, P. J., Thomas, P., Bajc, M., Jonson, B.
(2008). Merits of V/Q SPECT Scintigraphy Compared with CTPA in Imaging of Pulmonary Embolism. JNM
49: 167-168
[Full Text]
Freeman, L. M.
(2008). Don't Bury the V/Q Scan: It's as Good as Multidetector CT Angiograms with a Lot Less Radiation Exposure. JNM
49: 5-8
[Full Text]
Lu, M. T., Cai, T., Ersoy, H., Whitmore, A. G., Quiroz, R., Goldhaber, S. Z., Rybicki, F. J.
(2008). Interval Increase in Right-Left Ventricular Diameter Ratios at CT as a Predictor of 30-day Mortality after Acute Pulmonary Embolism: Initial Experience. Radiology
246: 281-287
[Abstract][Full Text]
Anderson, D. R., Kahn, S. R., Rodger, M. A., Kovacs, M. J., Morris, T., Hirsch, A., Lang, E., Stiell, I., Kovacs, G., Dreyer, J., Dennie, C., Cartier, Y., Barnes, D., Burton, E., Pleasance, S., Skedgel, C., O'Rouke, K., Wells, P. S.
(2007). Computed Tomographic Pulmonary Angiography vs Ventilation-Perfusion Lung Scanning in Patients With Suspected Pulmonary Embolism: A Randomized Controlled Trial. JAMA
298: 2743-2753
[Abstract][Full Text]
Jouveshomme, S., Bohn, I., Cazaban, A.
(2007). Diagnosis of pulmonary embolism in hospitalised patients: retrospective survey of an institutional standard. Eur Respir J
30: 1117-1123
[Abstract][Full Text]
Lyman, G. H., Khorana, A. A., Falanga, A., Clarke-Pearson, D., Flowers, C., Jahanzeb, M., Kakkar, A., Kuderer, N. M., Levine, M. N., Liebman, H., Mendelson, D., Raskob, G., Somerfield, M. R., Thodiyil, P., Trent, D., Francis, C. W.
(2007). American Society of Clinical Oncology Guideline: Recommendations for Venous Thromboembolism Prophylaxis and Treatment in Patients With Cancer. JCO
25: 5490-5505
[Abstract][Full Text]
Kramer, C. M., Budoff, M. J., Fayad, Z. A., Ferrari, V. A., Goldman, C., Lesser, J. R., Martin, E. T., Rajagopalan, S., Reilly, J. P., Rodgers, G. P., Wechsler, L.
(2007). ACCF/AHA 2007 Clinical Competence Statement on vascular imaging with computed tomography and magnetic resonance. Vasc Med
12: 359-378
Heyer, C. M., Mohr, P. S., Lemburg, S. P., Peters, S. A., Nicolas, V.
(2007). Image Quality and Radiation Exposure at Pulmonary CT Angiography with 100- or 120-kVp Protocol: Prospective Randomized Study. Radiology
245: 577-583
[Abstract][Full Text]
Goodman, L. R., Stein, P. D., Matta, F., Sostman, H. D., Wakefield, T. W., Woodard, P. K., Hull, R., Yankelevitz, D. F., Beemath, A.
(2007). CT Venography and Compression Sonography Are Diagnostically Equivalent: Data from PIOPED II. Am. J. Roentgenol.
189: 1071-1076
[Abstract][Full Text]
Remy-Jardin, M., Pistolesi, M., Goodman, L. R., Gefter, W. B., Gottschalk, A., Mayo, J. R., Sostman, H. D.
(2007). Management of Suspected Acute Pulmonary Embolism in the Era of CT Angiography: A Statement from the Fleischner Society. Radiology
245: 315-329
[Full Text]
(2007). For questions on page. Emerg. Med. J.
24: 742-742
[Full Text]
Kramer, C. M., Budoff, M. J., Fayad, Z. A., Ferrari, V. A., Goldman, C., Lesser, J. R., Martin, E. T., Rajagopalan, S., Reilly, J. P., Rodgers, G. P., Wechsler, L., Creager, M. A., Holmes, D. R. Jr, Merli, G., Newby, L. K., Pina, I., Rodgers, G. P., Weitz, H. H.
(2007). ACCF/AHA 2007 Clinical Competence Statement on Vascular Imaging With Computed Tomography and Magnetic Resonance: A Report of the American College of Cardiology Foundation/American Heart Association/American College of Physicians Task Force on Clinical Competence and Training Developed in Collaboration With the Society of Atherosclerosis Imaging and Prevention, the Society for Cardiovascular Angiography and Interventions, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, and the Society for Vascular Medicine and Biology. J Am Coll Cardiol
50: 1097-1114
[Full Text]
Strashun, A. M.
(2007). A Reduced Role of V/Q Scintigraphy in the Diagnosis of Acute Pulmonary Embolism. JNM
48: 1405-1407
[Full Text]
Gottschalk, A., Stein, P. D., Sostman, H. D., Matta, F., Beemath, A.
(2007). Very Low Probability Interpretation of V/Q Lung Scans in Combination with Low Probability Objective Clinical Assessment Reliably Excludes Pulmonary Embolism: Data from PIOPED II. JNM
48: 1411-1415
[Abstract][Full Text]
Wittram, C., Waltman, A. C., Shepard, J.-A. O., Halpern, E., Goodman, L. R.
(2007). Discordance between CT and Angiography in the PIOPED II Study. Radiology
244: 883-889
[Abstract][Full Text]
Meyer, G. S., Hales, C. A., Amrein, P. C., Sharma, A., Kradin, R. L.
(2007). Case 26-2007 -- A 61-Year-Old Man with Recurrent Fevers. NEJM
357: 807-816
[Full Text]
Goodman, L. R., Stein, P. D., Beemath, A., Sostman, H. D., Wakefield, T. W., Woodard, P. K., Yankelevitz, D. F.
(2007). CT Venography for Deep Venous Thrombosis: Continuous Images Versus Reformatted Discontinuous Images Using PIOPED II Data. Am. J. Roentgenol.
189: 409-412
[Abstract][Full Text]
Scarsbrook, A., Bradley, K., Gleeson, F., Groves, A. M., Yates, S. J., Win, T., Kayani, I., Bomanji, J., Ell, P. J.
(2007). Perfusion Scintigraphy Still has Important Role in Evaluation of Majority of Pregnant Patients with Suspicion of Pulmonary Embolism. Radiology
244: 623-625
[Full Text]
Harrington, D. W., Munekata, M. T.
(2007). Update in General Internal Medicine. ANN INTERN MED
147: 104-116
[Full Text]
Arakawa, H., Kohno, T., Hiki, T., Kaji, Y.
(2007). CT Pulmonary Angiography and CT Venography: Factors Associated with Vessel Enhancement. Am. J. Roentgenol.
189: 156-161
[Abstract][Full Text]
Wittram, C., Scott, J. A.
(2007). 18F-FDG PET of Pulmonary Embolism. Am. J. Roentgenol.
189: 171-176
[Abstract][Full Text]
Harris, B., Bailey, D., Miles, S., Bailey, E., Rogers, K., Roach, P., Thomas, P., Hensley, M., King, G. G.
(2007). Objective Analysis of Tomographic Ventilation-Perfusion Scintigraphy in Pulmonary Embolism. Am. J. Respir. Crit. Care Med.
175: 1173-1180
[Abstract][Full Text]
Tunariu, N., Gibbs, S. J.R., Win, Z., Gin-Sing, W., Graham, A., Gishen, P., AL-Nahhas, A.
(2007). Ventilation-Perfusion Scintigraphy Is More Sensitive than Multidetector CTPA in Detecting Chronic Thromboembolic Pulmonary Disease as a Treatable Cause of Pulmonary Hypertension. JNM
48: 680-684
[Abstract][Full Text]
Wittram, C.
(2007). How I Do It: CT Pulmonary Angiography. Am. J. Roentgenol.
188: 1255-1261
[Abstract][Full Text]
Scarsbrook, A. F., Gleeson, F. V.
(2007). Investigating suspected pulmonary embolism in pregnancy. BMJ
334: 418-419
[Full Text]
Segal, J. B., Eng, J., Tamariz, L. J., Bass, E. B.
(2007). Review of the Evidence on Diagnosis of Deep Venous Thrombosis and Pulmonary Embolism. Ann Fam Med
5: 63-73
[Abstract][Full Text]
Stein, P. D., Woodard, P. K., Weg, J. G., Wakefield, T. W., Tapson, V. F., Sostman, H. D., Sos, T. A., Quinn, D. A., Leeper, K. V. Jr, Hull, R. D., Hales, C. A., Gottschalk, A., Goodman, L. R., Fowler, S. E., Buckley, J. D.
(2007). Diagnostic Pathways in Acute Pulmonary Embolism: Recommendations of the PIOPED II Investigators. Radiology
242: 15-21
[Full Text]
(2006). ADDITIONAL ARTICLES ABSTRACTED IN ACP JOURNAL CLUB. Evid. Based Med.
11: 190-190
[Full Text]
Altschuler, E. L., Brotman, D. J., Stein, P. D., Goodman, L. R., Sostman, H. D.
(2006). Computed tomography for pulmonary embolism.. NEJM
355: 955-955
[Full Text]
(2006). Multidetector CT Scanners More Accurate Than Single-Detector for Diagnosing Pulmonary Embolism. JWatch Emergency Med.
2006: 7-7
[Full Text]
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