The evaluation of potential pulmonary embolism (PE) is one of the great challenges in emergency medicine. PE is notoriously overevaluated (with D-dimer testing and imaging) and also underevaluated, resulting in adverse outcomes. Medical providers have for many years faced a difficult time deciding when to initiate a workup with lab testing or imaging for possible PE.
Is clinical gestalt enough to decide on when to work up the patient? If so, how much clinical experience and knowledge of the literature is necessary to rely on that gestalt? When should D-dimer testing be performed? Which decision instruments (Pulmonary Embolism Rule-Out Criteria, or PERC; Wells criteria; revised Geneva score) are reliable and when should they be used? Concerns are continually raised about the financial costs associated with unnecessary workups as well as the dangers of contrast and radiation associated with pulmonary imaging.
In 2015, Raja and colleagues[1] published a wonderful "best practice advice" paperon behalf of the Clinical Guidelines Committee of the American College of Physicians that reviewed the literature and provided an evidence-based approach to the workup of the patient with possible PE. The suggested algorithm incorporated decision instruments and, in some cases, D-dimer testing to decide when the workup could be terminated versus when it should proceed to pulmonary imaging.
