Pulmonary Embolism: Sensitivity and Specificity

Introduction: Diagnosis of PE and DVT often merge, so diagnostic studies have been listed here for both. Also, see UpToDate article http://www.utdol.com/online/content/topic.do?topicKey=ven_pulm/6608 for details.

For presenting signs/symptoms, this is a great article: Am J Med. 2007 Oct;120(10):871-9. PMID: 17904458

Also note that Chronic Thromboembolic Pulmonary Hypertension is a different matter.

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Prevalence

Population / Calculator	Prevalence	Comments / Study / Link
Patients suspected of having PE	19.9%	in+outpatients referred for V/Q scan Am J Respir Crit Care Med. 2000 Dec;162(6):2105-8. PMID: 11112122
Well's criteria for PE	0%	Follow this link to a pre-test probability calculator for PE http://www.mdcalc.com/wells-criteria-for-pulmonary-embolism-pe/ Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer. Wells PS, Anderson DR, Rodger M, Ginsberg JS, Kearon C, Gent M, Turpie AG, Bormanis J, Weitz J, Chamberlain M, Bowie D, Barnes D, Hirsh J. http://www.schattauer.de/index.php?id=1268&pii=th00030416&no_cache=1
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The sensitivity and specificity of findings for Pulmonary Embolism are listed below. See the left navigation bar to change the display.

Sensitive and Specific Findings

Finding	Sensitivity	Specificity	Comments, Study
Leg US	93%	98%	for DVT by venography. this is "duplex ultrasound". Study: Ann Intern Med. 1989 Aug 15;111(4):297-304. PMID 2667418
MRA and MRV	92%	96%	BUT 52% of patients had technically inadequate results MRA alone had sens = 78% / spec = 99% and was technically inadequate in 25% of patients Study: PIOPED III Ann Int Med 2010 v152(7): 434 http://www.annals.org/content/152/7/434.abstract?etoc
CT angiography	90%	95%	multi-detector CT with CT venography Study: PIOPED II (NEJM 2006;354: 2317)

Specific Findings

Finding	Sensitivity	Specificity	Comments, Study
V/Q scan	77%	98%	about 25% of patients had an indeterminate scan and were excluded from this analysis. Study: Re-analysis of PIOPED II: Radiology. 2008 Mar;246(3):941-6. PMID: 18195380
Doppler Ultrasound	29%	97%	for PE Study: Ann Intern Med. 1997 May 15;126(10):775-81. PMID: 9148650
Abnormal Cardiac Exam	22%	88%	including: increased P2, right ventricular lift, or JVD Study: Am J Med. 2007 Oct;120(10):871-9. PMID: 17904458
No Typical Symptoms	12%	87%	no chest pain / hemoptysis / dyspnea as the presenting symptoms presentations were: tachycardia/tachypnea + signs/sxs of DVT, or hypoxemia, or other presentation Study: Am J Med. 2007 Oct;120(10):871-9. PMID: 17904458

Sensitive Findings

Finding	Sensitivity	Specificity	Comments, Study
Arterial Oxygen, D-dimer, or Respiratory Rate	96.9%	21.3%	PaO2 < 80, positive D-dimer, OR resp rate > 20 Study: Am J Respir Crit Care Med. 2000 Dec;162(6):2105-8. PMID: 11112122
Elevated D-dimer	95%	25%	positive is generally >500ng/ml In another study, D-dimer had 83% sensitivity and 58% specificity (PMID 11112122) Study: Ann Intern Med 2004 Apr 20;140(8):589-602. PMID: 15096330 Am J Respir Crit Care Med 1999; 160:1043.
Arterial Blood Gas or History of DVT	92.1%	21.1%	increased A-a gradient OR history of DVT/PE Study: Am J Respir Crit Care Med. 2000 Dec;162(6):2105-8. PMID: 11112122
Arterial Oxygen or History of DVT	91.9%	32.4%	PaO2 < 80 OR history of DVT/PE Study: Am J Respir Crit Care Med. 2000 Dec;162(6):2105-8. PMID: 11112122
Arterial Blood Gas Duplicate	91.9%	14.7%	increased A-a gradient OR PaCO2 < 36 Study: Am J Respir Crit Care Med. 2000 Dec;162(6):2105-8. PMID: 11112122
ECG	Sensitivity = 86.5%		any abnormality pooled from reproduced data (91% in this particular case series) Study: Chest. 1997 Mar;111(3):537-43. PMID: 9118684

Negative Findings

Finding	Sensitivity	Specificity	Comments, Study
No Typical Symptoms	12%	87%	no chest pain / hemoptysis / dyspnea as the presenting symptoms presentations were: tachycardia/tachypnea + signs/sxs of DVT, or hypoxemia, or other presentation Study: Am J Med. 2007 Oct;120(10):871-9. PMID: 17904458
Chest Pain	17%	79%	non-pleuritic Study: Am J Med. 2007 Oct;120(10):871-9. PMID: 17904458
Pleuritic Chest Pain or Hemoptysis	44%	44%	all comers. slightly lower rate in patients with PE but no prior cardiopulmonary disease Study: Am J Med. 2007 Oct;120(10):871-9. PMID: 17904458
Pleuritic Chest Pain	47%	41%	Study: Am J Med. 2007 Oct;120(10):871-9. PMID: 17904458

Poorly Diagnostic Findings

Finding	Sensitivity	Specificity	Comments, Study
Calf or Thigh Swelling	39%	80%	Study: Am J Med. 2007 Oct;120(10):871-9. PMID: 17904458
Homan's Sign	33%	79%	for DVT by venography. See http://www.turner-white.com/pdf/hp_mar01_homan.pdf for a full description. Briefly: "The patient�s knee should be in the flexed position. The examiner should forcibly and abruptly dorsiflex the patient�s ankle and observe for pain in the calf and popliteal region, which constitutes a positive sign". Study: Angiology. 1969 Apr;20(4):219-23. PMID 5778113
Signs of DVT	47%	77%	in calf or thigh: edema, erythema, tenderness, or palpable cord Study: Am J Med. 2007 Oct;120(10):871-9. PMID: 17904458
Calf or Thigh Pain	42%	75%	Study: Am J Med. 2007 Oct;120(10):871-9. PMID: 17904458
Dyspnea	36%	74%	dyspnea as the only presenting symptom Study: Am J Med. 2007 Oct;120(10):871-9. PMID: 17904458
Abnormal Lung Exam	37%	64%	including: crackles, wheezes, friction rub, etc Study: Am J Med. 2007 Oct;120(10):871-9. PMID: 17904458
pro BNP	60%	62%	>1.25pmol/L Study: J Thromb Haemost. 2006 Mar;4(3):552-6. Epub 2005 Dec 23. PMID 16405522
Tachypnea	57%	53%	RR > 20 Study: Am J Med. 2007 Oct;120(10):871-9. PMID: 17904458
Arterial Blood Gas Duplicate	84.2%	27.4%	increased A-a gradient Study: Am J Respir Crit Care Med. 2000 Dec;162(6):2105-8. PMID: 11112122
Tachycardia	Sensitivity = 60%		pooled from reproduced data - sensitivity = 36-90% depending on the case series. In this particular case series, it was not the most prevalent ECG finding; rather, T wave inversion was. In one other series, it was 90% prevalent (equivalent to TWI), and in PMID 123074, it is the most prevalent at 69% while TWI is only 42%. In this study, it was only present in 'massive' PE (defined by clot burden on PA cath). Study: Chest. 1997 Mar;111(3):537-43. PMID: 9118684
T-Wave Inversion	Sensitivity = 49%		anterior leads V1-V4 pooled from reproduced data - sensitivity ranges 42-89%; in this study it was the most prevalent ECG sign Study: Chest. 1997 Mar;111(3):537-43. PMID: 9118684
Low ECG Voltage	Sensitivity = 29%		Study: Chest. 1997 Mar;111(3):537-43. PMID: 9118684
S1 Q3 T3 Pattern	Sensitivity = 27.5%		S wave in I, Q wave in III, and inverted T in III pooled from reproduced data - sensitivity ranges 12-50% in different series Interestingly, despite the classical description of this feature as representing right heart strain, it was not predictive of massive PE in this case series. Study: Chest. 1997 Mar;111(3):537-43. PMID: 9118684
Right Bundle Branch Block	Sensitivity = 22%		Study: Chest. 1997 Mar;111(3):537-43. PMID: 9118684