DIAGNOSTIC ALGORITHMS

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DIAGNOSTIC ALGORITHMSDIAGNOSTIC ALGORITHMS

Doç. Dr. Güngör ÇAMSARIDoç. Dr. Güngör ÇAMSARI

Yedikule Teaching Hospital for Chest Yedikule Teaching Hospital for Chest Diseases and Thoracic Surgery, Diseases and Thoracic Surgery,

IstanbulIstanbul

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Venous Thromboembolism (VTE)Venous Thromboembolism (VTE)

Deep vein thrombosis (DVT) and pulmonary Deep vein thrombosis (DVT) and pulmonary embolism (PE) are both part of one entity: embolism (PE) are both part of one entity: VTEVTE

The annual incidence is for DVT and PE The annual incidence is for DVT and PE 1/1000 and 0,5/1000 respectively 1/1000 and 0,5/1000 respectively in in general population of the Western World and general population of the Western World and rises with age (1/100 population at 85 years).rises with age (1/100 population at 85 years).

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Mortality in untreated patients %30Mortality in untreated patients %30

Mortality in treated patients %2-8Mortality in treated patients %2-8

PE prevelance in hospitalized patients PE prevelance in hospitalized patients %12-15%12-15

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Diagnostic ProblemsDiagnostic Problems

The clinical signs and symptoms are The clinical signs and symptoms are nonspesificnonspesific

Decision of PE diagnosis and treatment with Decision of PE diagnosis and treatment with scintigraphy is possible in only scintigraphy is possible in only 40%40% of patients of patients

Pulmonary angiography (gold standart) is Pulmonary angiography (gold standart) is invasive, expensive and can cause invasive, expensive and can cause cardiopulmonary complicationscardiopulmonary complications

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Targets of Diagnostic Targets of Diagnostic StrategiesStrategies

- - Noninvasive methods, which can Noninvasive methods, which can decrease the need of pulmonary decrease the need of pulmonary angiography, should be the choice angiography, should be the choice

- Cost-effectiveness- Cost-effectiveness- Suitable for local conditionsSuitable for local conditions- Variability in different clinical Variability in different clinical

conditionsconditions

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Symptoms and SignsSymptoms and Signs

Sensitive, but not very spesific Sensitive, but not very spesific The presence of more than 1 clinical The presence of more than 1 clinical

sign or symptom increases sensitivitysign or symptom increases sensitivity Most common symptoms are dyspnea Most common symptoms are dyspnea

and pleuritic chest painand pleuritic chest pain Most common signs are tachypnea Most common signs are tachypnea

(>20/min) and tachycardia (>20/min) and tachycardia (>100/min)(>100/min)

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SymptomsSymptoms Dyspnea Dyspnea (80%)(80%) Pleuritic chest pain Pleuritic chest pain

(52%)(52%) Pain or edema in legsPain or edema in legs HemoptysisHemoptysis PalpitationPalpitation Anginal chest painAnginal chest pain Syncope/presyncopeSyncope/presyncope

SignsSigns Tachypnea (>20/min) Tachypnea (>20/min)

(70%)(70%) Tachycardia (>100/min) Tachycardia (>100/min)

(26%)(26%) CracklesCrackles Signs of DVTSigns of DVT Temperature >38 Temperature >38 ooC C Right gallop rhythmRight gallop rhythm

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Risk FactorsRisk Factors SurgerySurgery TraumaTrauma Immobilisation ( medical Immobilisation ( medical

illness, hospitalisation)illness, hospitalisation) Paralitic lower limbParalitic lower limb Previous VTE historyPrevious VTE history Malignancy+chemoterapMalignancy+chemoterap

yy AnesthesiaAnesthesia Central venous cathetersCentral venous catheters Genetic factorsGenetic factors

Pregnancy, puerperiumPregnancy, puerperium ObesityObesity Long distance travelLong distance travel Advanced ageAdvanced age Antiphospholipid syndromeAntiphospholipid syndrome Superficial venous Superficial venous

trombosistrombosis Oral contraceptives, Oral contraceptives,

hormon replacement hormon replacement therapytherapy

Other (polycythemia vera, Other (polycythemia vera, thrombocytosis, Behçet d.) thrombocytosis, Behçet d.)

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First-line Diagnostic TestsFirst-line Diagnostic Tests

- - Chest x-ray, ECG and arteriel blood Chest x-ray, ECG and arteriel blood gases gases are first line testsare first line tests

- 80% of patients with PE and no - 80% of patients with PE and no cardiopulmonary disease have an abnormal cardiopulmonary disease have an abnormal chest radiograph but this is also nonspesificchest radiograph but this is also nonspesific

- ECG, is useful for ruling out other processes - ECG, is useful for ruling out other processes and for detecting and evaluating signs and for detecting and evaluating signs (50%) of right ventricular overload but it is (50%) of right ventricular overload but it is also nonspesificalso nonspesific

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Chest X-Ray ECGChest X-Ray ECG

--Normal Normal - Normal- Normal

-Subsegmental atelectasis -Subsegmental atelectasis - Sinusal tachycardia- Sinusal tachycardia

-Small pleural effusions -Small pleural effusions - Right ventricular - Right ventricular overload overload

-Pleural-based opacities -Pleural-based opacities - Precordial T wave - Precordial T wave invertioninvertion

-Elevated hemidiafragm -Elevated hemidiafragm - Right bundle branch - Right bundle branch blockblock

-Cardiovascular pathologies -Cardiovascular pathologies - S1 Q3 T3 pattern- S1 Q3 T3 pattern

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Arterial Blood GasesArterial Blood Gases Arterial hypoxemia and respiratory alkalosis Arterial hypoxemia and respiratory alkalosis

are commonare common

In the PIOPED and PISAPED studies, over In the PIOPED and PISAPED studies, over 80% of patients presented 80% of patients presented basal PaO2 <80 basal PaO2 <80 mmHgmmHg and hypocapnia and hypocapnia

PaOPaO22 < 80 mmHg; < 80 mmHg; sensitivity: 57%, spesificity:53%sensitivity: 57%, spesificity:53%

Hypoxemia is related on age, alveolo-arterial Hypoxemia is related on age, alveolo-arterial gradient is increasedgradient is increased

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Symptoms and signsSymptoms and signs+ +

Risk factorsRisk factors+ +

First line diagnostic testsFirst line diagnostic tests

Clinical ProbabilityClinical Probability(low, moderate, high)(low, moderate, high)

Assessment of Clinical Probability

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Wells ScaleWells Scale

PE, most likely diagnosis PE, most likely diagnosis : 3 point: 3 point Signs of DVT : 3 pointSigns of DVT : 3 point Previous DVT or PE Previous DVT or PE : 1,5 point: 1,5 point Heart rate > 100 beats/min Heart rate > 100 beats/min : 1,5 point: 1,5 point Immobilization or surgery (pre. 4 w) Immobilization or surgery (pre. 4 w) : 1,5 point: 1,5 point Cancer treated in the prior 6 month Cancer treated in the prior 6 month : 1 point: 1 point Hemoptysis : 1 pointHemoptysis : 1 point

Clinical probability Clinical probability <2: low<2: low, , 2-6: moderate2-6: moderate, , >6 high>6 high

Ann Intern Med Ann Intern Med 1998;129:9971998;129:997

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Geneva Rules (Wicki )Geneva Rules (Wicki ) Recent surgeryRecent surgery : 3 point: 3 point Previous DVT or PE Previous DVT or PE : 2 point: 2 point PaO2:PaO2: < 48.7 < 48.7 mmHg mmHg : 4 point: 4 point 48.7-60 mmHg 48.7-60 mmHg : 3 point: 3 point 60-71.2 mmHg 60-71.2 mmHg : 2 point: 2 point 71.3–82.4 mmHg 71.3–82.4 mmHg : 1 point: 1 point PaCO2:PaCO2: < 36 < 36 mmHg mmHg : 2 point: 2 point 36-38.9 mm Hg 36-38.9 mm Hg : 1 point: 1 point Age:Age: > 80 > 80 : 2 point: 2 point 60-79 60-79 : 1 point: 1 point Pulse rate :Pulse rate : > 100 beats/min > 100 beats/min : 1 point: 1 point Radiologic patology:Radiologic patology:

atelectasis atelectasis : 1 point: 1 point elevation of hemidiafragmelevation of hemidiafragm : 1 point: 1 point

Clinical probability Clinical probability 0-4: low0-4: low, , 5-8 moderate5-8 moderate, , > 9 high> 9 high

Arch Intern Med 2001;161:92 Arch Intern Med 2001;161:92

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Le Gal ScaleLe Gal Scale Age >65 Age >65 : 1 point: 1 point Previous DVT or PE Previous DVT or PE : 3 point: 3 point Surgery (during the previous 1 mo)Surgery (during the previous 1 mo) : 2 point: 2 point Active malignant condition Active malignant condition : 2 point: 2 point Unilateral lower limb pain Unilateral lower limb pain : 3 point: 3 point Hemoptysis Hemoptysis : 2 point: 2 point Heart rateHeart rate 75-94 75-94 : 3 point: 3 point >95 : 5 point>95 : 5 point Pain on leg palpation or edema Pain on leg palpation or edema : 4 point: 4 point

Clinical probability Clinical probability 0-3: low0-3: low, , 4-10: moderate4-10: moderate, , >11: high>11: high

Ann Intern Med Ann Intern Med 2006;144:165 2006;144:165

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Prevelance of PE according to Prevelance of PE according to Clinical ProbabilityClinical Probability

Clinical Clinical probabilityprobability

PE suspected patientsPE suspected patients

PIOPEDPIOPED WellsWells WickiWicki Le GalLe Gal

887 (E,I)887 (E,I) 1239 1239 (E,I)(E,I)

1090 1090 (E,I)(E,I) 234 (E,I)234 (E,I)

LowLow %9%9 %4%4 %10%10 %8%8

IntermediateIntermediate %30%30 %21%21 %38%38 %28%28

HighHigh %68%68 %67%67 %81%81 %74%74

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Evaluation of clinical probability is not Evaluation of clinical probability is not sufficient for diagnosis and decision of sufficient for diagnosis and decision of treatment in PEtreatment in PE

Clinical probability should be evaluated Clinical probability should be evaluated together withtogether with D-dimer, scintigraphy, D-dimer, scintigraphy, spiral CT, lower limb compression spiral CT, lower limb compression ultrasonography for diagnosisultrasonography for diagnosis

Clinical Probability

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D-DimerD-Dimer

D-Dimer is a specific product of fibrin D-Dimer is a specific product of fibrin degradationdegradation

Highly sensitive markers for VTE but Highly sensitive markers for VTE but spesificity is low (in outpatients 40%)spesificity is low (in outpatients 40%)

The level of D-Dimer increases in infectious The level of D-Dimer increases in infectious diseases, pregnancy, cancer, trauma, diseases, pregnancy, cancer, trauma, surgery, stroke, myocard infarctionsurgery, stroke, myocard infarction

D-Dimer is useful for excluding VTE with low D-Dimer is useful for excluding VTE with low clinical probability (in outpatients)clinical probability (in outpatients)

In hospitalized and old patients is not useful In hospitalized and old patients is not useful

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D-Dimer Measurement D-Dimer Measurement TechniquesTechniques

ELISA techniques or turbidimetrics are the ELISA techniques or turbidimetrics are the most sensitive quantitative techniquesmost sensitive quantitative techniques

When ELISA tecniques used <500ng/ml D-When ELISA tecniques used <500ng/ml D-

Dimer excludes VTE Dimer excludes VTE 95-99%95-99% Red cell agglutination (SimpliRED), latex Red cell agglutination (SimpliRED), latex

agglutination, immunochromatography or agglutination, immunochromatography or immunonfiltration are more subjective immunonfiltration are more subjective qualitative tests qualitative tests

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Low clinical probability:Low clinical probability: (-) D-Dimer (-) D-Dimer tests reliably excludes VTEtests reliably excludes VTE

Intermediate clinical probabilityIntermediate clinical probability: (-) D-: (-) D-Dimer (only with ELISA tecniques) Dimer (only with ELISA tecniques) excludes VTEexcludes VTE

High clinical probabilityHigh clinical probability: D-Dimer : D-Dimer

should not be used. It doesn’t exclude VTE should not be used. It doesn’t exclude VTE (negative predictive value <80%)(negative predictive value <80%)

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ScintigraphyScintigraphy

Lung scintigraphy should be performed Lung scintigraphy should be performed within 24 hours of the onset of symptoms within 24 hours of the onset of symptoms in patients with suspected PEin patients with suspected PE

Perfusion scintigraphy is sensitive but Perfusion scintigraphy is sensitive but

specifity is lowspecifity is low

If ventilation scan couldn’t be performed, If ventilation scan couldn’t be performed, perfusion scan should be assessed with perfusion scan should be assessed with chest x-raychest x-ray

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AA normal perfusion scintigraphy normal perfusion scintigraphy rules out PE rules out PE (negative predictive (negative predictive value 99%)value 99%)

High-probability scintigraphyHigh-probability scintigraphy, , is is false false positive in 15%positive in 15% of patients with of patients with suspected PEsuspected PE

PE prevelance is 25% with low or PE prevelance is 25% with low or intermediate (non-diagnostic) intermediate (non-diagnostic) perfusion scintigraphyperfusion scintigraphy

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PIOPED: Clinical probability PIOPED: Clinical probability assessment and V/Q assessment and V/Q

scintigraphyscintigraphy Clinical probabilityClinical probability

Scintigraphic Scintigraphic probabilityprobability HighHigh IntermediaIntermedia

teteLowLow

HighHigh %96%96 %88%88 %56%56

IntermediateIntermediate %66%66 %28%28 %16%16

LowLow %40%40 %16%16 %4%4

Normal/near Normal/near normal normal %0%0 %6%6 %2%2

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PE can’t be diagnosed or ruled out in nPE can’t be diagnosed or ruled out in non-on- diagnostic scintigraphy patterns or a diagnostic scintigraphy patterns or a

high high probability scintigraphy and lower probability scintigraphy and lower

clinicalclinical probabilityprobability (these patterns are seen in (these patterns are seen in

60% of 60% of patients) patients)

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Scintigraphic Patterns of High Scintigraphic Patterns of High Probability for Pulmoner Probability for Pulmoner

EmbolismEmbolism According to PIOPED study According to PIOPED study ::

- 2 or more large segmental perfusion defects (>2 or more large segmental perfusion defects (>% 75 of a segment) without corresponding % 75 of a segment) without corresponding abnormalities in ventilation or chest abnormalities in ventilation or chest radiograph, or defect substantially larger than radiograph, or defect substantially larger than 75%75%

- 2 or more mismatched moderate segmental 2 or more mismatched moderate segmental perfusion defects (% 25-75 of a segment) and perfusion defects (% 25-75 of a segment) and 1 large segmental defect 1 large segmental defect

- At least 4 moderate defects without At least 4 moderate defects without abnormalities in ventilation or chest abnormalities in ventilation or chest radiograph. radiograph.

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Problems in Scintigraphic Problems in Scintigraphic AssessmentAssessment

There is no agreed consistent terminology There is no agreed consistent terminology for reportingfor reporting

Intraobserver disagreement or Intraobserver disagreement or interobserver disagreement 10-20% interobserver disagreement 10-20%

Ventilation Scintigraphy increases specifity Ventilation Scintigraphy increases specifity and but also cost and but also cost

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Spiral CT AngiographySpiral CT Angiography Spiral CTA was developed during the early 1990sSpiral CTA was developed during the early 1990s Sensitivity and specificity are low in Sensitivity and specificity are low in

subsegmental arteries (6-22% of patients) subsegmental arteries (6-22% of patients) In prospective studies comparing CTA with lung In prospective studies comparing CTA with lung

scintigrapy, it was found that CTA had a scintigrapy, it was found that CTA had a substantially higher level of interobserver substantially higher level of interobserver agreement and greater specifityagreement and greater specifity

In many cases it provides an alternative diagnosisIn many cases it provides an alternative diagnosis CTA is currently available in most hospitalCTA is currently available in most hospital

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Accuracy of diagnostic tests for PE

TestTest Sensitivity (%)Sensitivity (%) Specificity (%)Specificity (%)

D-dimerD-dimer 90-9990-99 40-6040-60

USUS 3535 9999

V/Q scanV/Q scan 9898 1010

Spiral CTSpiral CT 57-10057-100 78-10078-100

MRIMRI 71-8771-87 95-9795-97

AngiographyAngiography 9898 94-9894-98

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Search for Deep Venous Thrombosis

ContrastContrast venography:venography: Gold standart for DVT diagnosisGold standart for DVT diagnosis Limitations:Limitations:

Expensive and invasive procedureExpensive and invasive procedure Allergic reactions and phlebitis may developAllergic reactions and phlebitis may develop Experimentation is necessary for interpretation Experimentation is necessary for interpretation

Wrong interpretation is frequent in massive Wrong interpretation is frequent in massive

thrombus thrombus

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Contrast venographyContrast venography

Clinical probability of DVT high and Clinical probability of DVT high and noninvasive tests are nondiagnostic or noninvasive tests are nondiagnostic or

impossible to performimpossible to perform

BeforeBefore VCI filters were inserted VCI filters were inserted

contrast venography contrast venography should be doneshould be done

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Compression UltrasoundCompression Ultrasound

Most used noninvasive test for detecting Most used noninvasive test for detecting DVTDVT

In symptomatic acute proximal thrombosis In symptomatic acute proximal thrombosis sensitivity 97%, specificity 98%sensitivity 97%, specificity 98%

Sensitivity 38% in asymptomatic casesSensitivity 38% in asymptomatic cases In symptomatic and DVT suspicious cases In symptomatic and DVT suspicious cases

a negative examination doesn’t reliably a negative examination doesn’t reliably exclude DVT (serial US must be done)exclude DVT (serial US must be done)

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Compression UltrasoundCompression Ultrasound

In patients with co-existing clinical In patients with co-existing clinical DVT, leg ultrasound as the initial DVT, leg ultrasound as the initial imaging test is often sufficient to imaging test is often sufficient to confirm VTEconfirm VTE

A single normal leg ultrasound is not A single normal leg ultrasound is not reliable for exclusion of subclinical reliable for exclusion of subclinical DVT DVT

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CT venographyCT venography

Sensitivity and specificity in small Sensitivity and specificity in small case series are over 95% in the case series are over 95% in the femoropopliteal regionfemoropopliteal region

Gonadal radiation risk is highGonadal radiation risk is high More studies are neededMore studies are needed

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Magnetic Resonance ImagingMagnetic Resonance Imaging

Sensitivity and specificity for PE were high Sensitivity and specificity for PE were high in studies of a small number of casesin studies of a small number of cases

An alternative to CTA in patients with renal An alternative to CTA in patients with renal failure or allergy to contrast agentsfailure or allergy to contrast agents

It is useful for detecting DVT in venous It is useful for detecting DVT in venous areas that are hard to study, such as the areas that are hard to study, such as the pelvis or the VCIpelvis or the VCI

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DIAGNOSIS OF DVTDIAGNOSIS OF DVT ( (ATS 1999ATS 1999))

Suspected Acute DVTSuspected Acute DVT

Compression USCompression US

Normal Inconclusive DVT (+) Normal Inconclusive DVT (+)

or or

Seri US Inadequate study TreatSeri US Inadequate study Treat

(+) (-) (+) (-) venography or MRIvenography or MRI

TreatTreat

DVT(-) DVT(+)DVT(-) DVT(+)

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EchocardiographyEchocardiography

It is used as a severity marker to detect RV It is used as a severity marker to detect RV dysfunctiondysfunction

It can identify intracardiac and main pulmonary artery It can identify intracardiac and main pulmonary artery thrombithrombi

In the cases who have right ventricul overloading In the cases who have right ventricul overloading sensitivity 80%, specificity 97% sensitivity 80%, specificity 97%

It is useful to guide urgent therapeutic decisions like It is useful to guide urgent therapeutic decisions like

It is useful in differential diagnosis (MI, aorta It is useful in differential diagnosis (MI, aorta dissection etc.) dissection etc.)

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Transözofagiyal Ekokardiyografi !

MASİF PE / EKOKARDİYOGRAFİ

Sağ ventrikülde dilatasyon ve hipokinezisi

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Pulmonary AngiographyPulmonary Angiography

Gold standart testGold standart test Morbidity is 0.2%, mortality is 0.5% Morbidity is 0.2%, mortality is 0.5% Interobserver agreement in interpretation Interobserver agreement in interpretation

of subsegmental arteries is poor of subsegmental arteries is poor DSA and generalized use of non-ionic DSA and generalized use of non-ionic

contrast materials have minimized riskscontrast materials have minimized risks

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Diagnostic Strategies Diagnostic Strategies Capable of Excluding the Capable of Excluding the

Diagnosis of PEDiagnosis of PEClinical Probability

Low Moderate High

(-) D-dimer (-) D-dimer (ELISA) Normal V/Q scanNormal V/Q scan Normal V/Q scan (-) Pulmonary angiography(-) CT angiography + (-) DUS (-) CT angiography + (-) DUSNon-diagnostic V/Q scan + (-) serial DUS Non-diagnostic V/Q scan + (-) serial DUS(-) Pulmonary angiography (-) Pulmonary angiography

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Diagnostic Strategies Diagnostic Strategies Capable of Confirming the Capable of Confirming the

Diagnosis of PEDiagnosis of PEClinical Probability

Low Moderate High

(+) CT Angiography (+) CT Angiografi (+) CT Angiography (+) Pulmonary Angiography (+) Pulmonary Angiography (+) Pulmonary Angiography (+) DUS (+) DUS (+) DUS High probability V/Q scan High probability V/Q scan

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Diagnostic Algorithms for Diagnostic Algorithms for Hemodynamically Stable PEHemodynamically Stable PE

1. Round: 1. Round: ToTo rule out the diagnosis of PErule out the diagnosis of PE

D-dimer and clinical probability is usedD-dimer and clinical probability is used (-) D-Dimer + low clinical probability: PE excluded(-) D-Dimer + low clinical probability: PE excluded (-) D-Dimer (ELISA) + intermediate clinical probability: PE (-) D-Dimer (ELISA) + intermediate clinical probability: PE

excludedexcluded

CT Angiography or Lung scintigraphy CT Angiography or Lung scintigraphy as the initial testas the initial test

CTA is not cost-effective as a first line diagnostic testCTA is not cost-effective as a first line diagnostic test Scintigraphy resuls are only normal in a small minority of Scintigraphy resuls are only normal in a small minority of

cases (fewer than 20%)cases (fewer than 20%)

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2. Round:2. Round: To confirm the diagnosis of PE To confirm the diagnosis of PE using noninvasive diagnostic testsusing noninvasive diagnostic tests

Scintigraphy, CT AngiographyScintigraphy, CT Angiography or or Ultrasound Ultrasound

will be the first choice for this purposewill be the first choice for this purpose In recent years, CTA and US are acceptedIn recent years, CTA and US are accepted

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IfIf;; facilities are available on sitefacilities are available on site chest radiograph is normalchest radiograph is normal no co-existing cardiopulmonary no co-existing cardiopulmonary

disease is presentdisease is present standardised reporting criteria are standardised reporting criteria are

usedused

SCINTIGRAPHY may be considered as SCINTIGRAPHY may be considered as the the initialinitial imaging investigation imaging investigation

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3. Round:3. Round: Gold standart tests (Pulmonary Gold standart tests (Pulmonary angiograpy and contrast venography)angiograpy and contrast venography)

P. angiography is indicated when high P. angiography is indicated when high clinical probability + inconclusive diagnostic clinical probability + inconclusive diagnostic test results are present (especially in test results are present (especially in patients at risk for hemorrhage)patients at risk for hemorrhage)

Venography is used only to avoid Venography is used only to avoid P.angiograhyP.angiograhy

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IntermediateLow High

D-Dimer(ELISA or other methods)

D-Dimer(ELISA)

(-) (+)

Exclude pulmonary embolism

(-) (+)

Lung scan or Spiral CT

High probability Non diagnostic Normal

US(+) (-)

Low Intermediate High

Angiography


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Clinically suspected non massive PE

Clinical probability of PE assessment

Plasma D-dimer

< 500 μg/L,no treatment

≥ 500 μg/L

US

DVTtreat

no DVT

Lung scan

Normal/near normal, Non diagnostic High probability,no treatment treat

Low clinical probability Clinical probability of PEof PE (as assessed initially) intermediate or highno treatment

Angiography(spiral CT*) Negative,no treatment

Positive, treat

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Diagnosis in Hospitalized Diagnosis in Hospitalized Patients and ComorbidityPatients and Comorbidity

D-DimerD-Dimer is not reliable is not reliable Predictive value of Predictive value of clinical probabilityclinical probability is low is low Spiral CT is preferredSpiral CT is preferred instead of scintigraphy instead of scintigraphy If scintigraphy is chosen, If scintigraphy is chosen, V/Q scintigraphyV/Q scintigraphy

should be doneshould be done If initial If initial USUS ise (-), serial investigations should ise (-), serial investigations should

be donebe done EchocardiographyEchocardiography is an important test in the is an important test in the

excessive hypoxemic patientsexcessive hypoxemic patients..

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Diagnostic Algorithm for Diagnostic Algorithm for Unstable PEUnstable PE

No validated algorithm is availableNo validated algorithm is available D-Dimer and clinic probability are not usedD-Dimer and clinic probability are not used In general most commonly used tests areIn general most commonly used tests are CT angiography and echocardiographyCT angiography and echocardiography Another effective option is Another effective option is arteriographyarteriography (for diagnosis and treatment of massive (for diagnosis and treatment of massive

embolus embolus with fibrinolysis)with fibrinolysis)

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Diagnostic algorithm for unstable or massive Diagnostic algorithm for unstable or massive PE suspected patientsPE suspected patients

Thrombus (+) Thrombus (–)Thrombus (+) Thrombus (–)

Anticoagulant th . ECHOAnticoagulant th . ECHO

ECHO NormalECHO Normal

Right vent.disfunc.,thrombus Pulmonary Right vent.disfunc.,thrombus Pulmonary angiograpyangiograpy

Thrombolitic therapy (+)Continue tr. (-) Stop Thrombolitic therapy (+)Continue tr. (-) Stop tr.tr.

Start anticoagulant tr.+ US(or spiral CT)

Thrombolitic therapy

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