Validación de una estrategia diagnóstica basada en aplicación de criterios clínicos, niveles de dímero-D y angio tomografía computarizada torácica para descartar embolia pulmonar en un servicio de urgencias

Abstract

Objective: To assess the clinical effectiveness of a simplified algorithm using the Wells clinical decision rule, D-dimer testing, and computed tomography (CT) in patients with suspected pulmonary embolism. Methods: Patients with clinically suspected PE from the emergency department from May 2007 through December 2008 were included. Clinical probability was assessed using the Wells clinical decision rule. As the ELISA Ddimer test was not available at the time of enrollment, all patients with suspected PE underwent CT. Anticoagulants were withheld from patients in whom PE was excluded and were followed up for 3 months. After enrollment was completed a VIDAS D-dimer assay was used to measure D-dimer concentration in frozen samples. Then the rate of patients with unlikely pulmonary embolism according to a clinical decision rule and a normal D-dimer test (< 500 ng/ml) was assessed. Results: The prevalence of PE in the entire population was 23,6%. The combination of a low or intermediate probability using the original Wells clinical decision rule and normal D-dimer level occurred in 26,9%, and in 23,6% when the combination of a low probability applying the dichotomized Wells score was used, thus making CT unnecessary. During the follow-up period, no thromboembolic events were recorded and there were no deaths related to venous thromboembolic disease (3-month thromboembolic risk 0% [95% CI, 0%-8%]). Conclusions: A diagnostic management strategy using a simple clinical decision rule, D-dimer testing, and CT is effective in the evaluation and management of patients with clinically suspected pulmonary embolism. Its use is associated with low risk for subsequent fatal and nonfatal VTE.