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All That Glitters Is Not Gold in Pursuing the Diagnosis of Pulmonary EmbolismDiagnosing Pulmonary Embolism FREE TO VIEW

Sami O. Simons, MD; Sandra L. Snijders, MD
Author and Funding Information

From the Department of Pulmonary Medicine, Radboud University Nijmegen Medical Centre.

Correspondence to: Sami O. Simons, MD, Radboud University Nijmegen Medical Centre, Department of Pulmonary Medicine-454, PO Box 9101, 6500 HB Nijmegen, The Netherlands; e-mail: s.simons@long.umcn.nl


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2012 American College of Chest Physicians


Chest. 2012;141(1):276-277. doi:10.1378/chest.11-1976
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Published online

To the Editor:

We read with great interest the study by Moores and colleagues1 published in a recent issue of CHEST (August 2011). It gives an up-to-date, balanced overview of the approach to the diagnosis of acute nonmassive pulmonary embolism.

In their review, they elaborately discuss the benefits of clinical decision rules and D-dimer testing, making a compelling argument that the high sensitivity of D-dimer testing makes this test especially attractive for ruling out pulmonary embolism. They recommend D-dimer testing as the first-line test if patients have a low or intermediate pretest probability of disease.

We have, however, missed a balanced discussion on the benefits and difficulties of diagnostic procedures such as clinical decision rules and D-dimer testing in two special populations, namely patients who are pregnant and patients with chronic renal failure. Proper diagnosis of pulmonary embolism is important in these two populations since the prevalence of pulmonary embolism is higher than in the general population,2,3 especially in patients who are pregnant.

An approach to the diagnostic management is very challenging in both populations, unfortunately. First, since they have been exclusively excluded from nearly all trials on the diagnosis of pulmonary embolism, neither clinical decision rules nor D-dimer testing has been validated in both populations. Second, symptoms of a VTE, such as tachycardia, tachypnea, and leg swelling, are often seen both in patients who are pregnant as a physiologic phenomenon and in patients on dialysis as a sign of fluid overload. Last, there is a physiologic increase of D-dimer in both populations,2,4 decreasing the specificity of this test. Given the paucity of data, what are the authors’ thoughts on the diagnosis of pulmonary embolism in patients who are pregnant and in patients with chronic renal failure?

Moores LK, King CS, Holley AB. Current approach to the diagnosis of acute nonmassive pulmonary embolism. Chest. 2011;1402:509-518 [PubMed] [CrossRef]
 
Bourjeily G, Paidas M, Khalil H, Rosene-Montella K, Rodger M. Pulmonary embolism in pregnancy. Lancet. 2010;3759713:500-512 [PubMed]
 
Tveit DP, Hypolite IO, Hshieh P, et al. Chronic dialysis patients have high risk for pulmonary embolism. Am J Kidney Dis. 2002;395:1011-1017 [PubMed]
 
Karami-Djurabi R, Klok FA, Kooiman J, Velthuis SI, Nijkeuter M, Huisman MV. D-dimer testing in patients with suspected pulmonary embolism and impaired renal function. Am J Med. 2009;12211:1050-1053 [PubMed]
 

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References

Moores LK, King CS, Holley AB. Current approach to the diagnosis of acute nonmassive pulmonary embolism. Chest. 2011;1402:509-518 [PubMed] [CrossRef]
 
Bourjeily G, Paidas M, Khalil H, Rosene-Montella K, Rodger M. Pulmonary embolism in pregnancy. Lancet. 2010;3759713:500-512 [PubMed]
 
Tveit DP, Hypolite IO, Hshieh P, et al. Chronic dialysis patients have high risk for pulmonary embolism. Am J Kidney Dis. 2002;395:1011-1017 [PubMed]
 
Karami-Djurabi R, Klok FA, Kooiman J, Velthuis SI, Nijkeuter M, Huisman MV. D-dimer testing in patients with suspected pulmonary embolism and impaired renal function. Am J Med. 2009;12211:1050-1053 [PubMed]
 
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