Safety and efficiency of diagnostic strategies for ruling out pulmonary embolism in patients with chronic lung disease: an individual-patient data meta-analysis.

Mai V
Takada T
Kraaijpoel N
van Es N
Mallick R
Stals MAM, et al.

J Thromb Haemost. 2025 Oct 27:S1538-7836(25)00667-1. doi: 10.1016/j.jtha.2025.10.004. (Original)
PMID: 41161416

Read abstract

Disciplines

Emergency Medicine

Relevance - 6/7
Newsworthiness - 6/7
Hemostasis and Thrombosis

Relevance - 5/7
Newsworthiness - 5/7
Hospital Doctor/Hospitalists

Relevance - 5/7
Newsworthiness - 4/7
Internal Medicine

Relevance - 5/7
Newsworthiness - 4/7
Respirology/Pulmonology

Relevance - 5/7
Newsworthiness - 4/7

Abstract

BACKGROUND: The optimal diagnostic management of patients with chronic lung disease (CLD) and suspected pulmonary embolism (PE) is unclear.

OBJECTIVES: The aim of this study was to evaluate the performance of PE diagnostic strategies in patients with and without CLD.

METHODS: This is a secondary analysis of an individual-patient data meta-analysis (PROSPERO CRD42018089366) of prospective or cross-sectional studies evaluating conventional (Wells or revised Geneva score with fixed or age-adjusted D-dimer) and newer (YEARS and the Pulmonary Embolism Graduated D-dimer Study algorithms) diagnostic strategies. Main outcomes were safety and efficiency. Safety was defined by the failure rate (proportion of patients diagnosed with venous thromboembolism during initial workup or follow-up among those in whom PE was considered ruled out at baseline without imaging). Efficiency was defined as the proportion of patients in whom PE was considered excluded without the need for imaging among all patients.

RESULTS: Twelve studies, representing 16 990 patients (2201 patients with CLD) were included. The safety of each strategy was comparable in patients with and without CLD, whereas efficiency of the strategies was lower in patients with CLD. In patients with CLD, the predicted failure rate varied between 0.58% (95% CI, 0.10%-3.20%) and 1.06% (95% CI, 0.44%-2.53%), and between 2.54% (95% CI, 1.45%-4.39%) and 3.12% (95% CI, 2.04%-4.74%) for conventional and newer diagnostic strategies, respectively. The predicted efficiency was 19.0% to 33.2% and 35.8% to 43.9% for conventional and newer diagnostic strategies, respectively.

CONCLUSION: In patients with CLD, diagnostic failure rate seemed slightly lower with conventional diagnostic strategies, but more patients would need imaging to rule out PE, compared with newer diagnostic strategies.

Clinical Comments

Emergency Medicine

The safest and most effective diagnostic approach to suspected pulmonary embolism has been debated for decades (see https://emergencymedicine.wustl.edu/items/distinguishing-low-risk-from-no-risk-pe-patients-in-em/ and https://emergencymedicine.wustl.edu/items/diagnosing-pulmonary-embolism/ and https://emergencymedicine.wustl.edu/items/reducing-pe-protocol-ct-ordering-rates-in-the-ed/ and https://emergencymedicine.wustl.edu/items/age-adjusted-d-dimer-to-exclude-pulmonary-embolism/ and https://emergencymedicine.wustl.edu/the-diagnostic-evaluation-of-pulmonary-embolism/. Patients with chronic lung disease add another wrinkle to the equation and these authors provide a comparative analysis of various PE diagnostic strategies for those individuals that is worthwhile knowledge for emergency physicians.

Emergency Medicine

This individual patient-level meta-analysis found that diagnostic strategies to rule out PE without imaging were generally less efficient, but with similar failure (false-negative) rates among patients with chronic lung disease compared with patients without. Unsurprisingly, the most efficient strategies (YEARS or PEGED risk adjusted D-dimer thresholds) had the highest failure rates, which were above the generally accepted failure rate of 2%. These findings suggest that it may not be safe at currently accepted thresholds for missing a PE. Wells and Geneva risk stratification with set or age-adjusted D-dimer thresholds had failure rates <2%. Of note, the parent study found higher failure rates across strategies for patients with active cancer or a history of VTE, so particular caution might be warranted when considering applying YEARS or PEGED in these populations.

Respirology/Pulmonology

This a secondary analysis looking at a subset of patients with chronic lung disease included in a meta-analysis. I find the scientific validity of this approach questionable. Regardless, the findings are unlikely to change practice.

Register for free access to all Professional content

Want the latest in aging research? Sign up for our email alerts.

Our Content

About

Support for the Portal is largely provided by the Labarge Optimal Aging Initiative. AGE-WELL is a contributing partner. Help us to continue to provide direct and easy access to evidence-based information on health and social conditions to help you stay healthy, active and engaged as you grow older. Donate Today.