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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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Tags: Hematologic Pulmonary Tag this Diagnosis.

Prevalence

Population / CalculatorPrevalence 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

More, Edit...

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 SensitivitySpecificity Comments, Study
Leg US Edit 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 Edit 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 Edit 90%95%

multi-detector CT with CT venography

Study: PIOPED II (NEJM 2006;354: 2317)

Specific Findings

Finding SensitivitySpecificity Comments, Study
V/Q scan Edit 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 Edit 29%97%

for PE

Study: Ann Intern Med. 1997 May 15;126(10):775-81. PMID: 9148650

Abnormal Cardiac Exam Edit 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 Edit 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 SensitivitySpecificity Comments, Study
Arterial Oxygen, D-dimer, or Respiratory Rate Edit 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 Edit 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 Edit 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 Edit 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 Edit
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 Edit 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 SensitivitySpecificity Comments, Study
No Typical Symptoms Edit 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 Edit 17%79%

non-pleuritic

Study: Am J Med. 2007 Oct;120(10):871-9. PMID: 17904458

Pleuritic Chest Pain or Hemoptysis Edit 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 Edit 47%41%

Study: Am J Med. 2007 Oct;120(10):871-9. PMID: 17904458

Poorly Diagnostic Findings

Finding SensitivitySpecificity Comments, Study
Calf or Thigh Swelling Edit 39%80%

Study: Am J Med. 2007 Oct;120(10):871-9. PMID: 17904458

Homan's Sign Edit 33%79%

for DVT by venography.

See http://www.turner-white.com/pdf/hp_mar01_homan.pdf for a full description. Briefly: "The patientís knee should be in the flexed position. The examiner should forcibly and abruptly dorsiflex the patientís 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 Edit 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 Edit 42%75%

Study: Am J Med. 2007 Oct;120(10):871-9. PMID: 17904458

Dyspnea Edit 36%74%

dyspnea as the only presenting symptom

Study: Am J Med. 2007 Oct;120(10):871-9. PMID: 17904458

Abnormal Lung Exam Edit 37%64%

including: crackles, wheezes, friction rub, etc

Study: Am J Med. 2007 Oct;120(10):871-9. PMID: 17904458

BNP Edit 60%62%

>1.25pmol/L

Study: J Thromb Haemost. 2006 Mar;4(3):552-6. Epub 2005 Dec 23. PMID 16405522

Tachypnea Edit 57%53%

RR > 20

Study: Am J Med. 2007 Oct;120(10):871-9. PMID: 17904458

Arterial Blood Gas
Duplicate Edit
84.2%27.4%

increased A-a gradient

Study: Am J Respir Crit Care Med. 2000 Dec;162(6):2105-8. PMID: 11112122

Tachycardia Edit 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 Edit 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 Edit Sensitivity = 29%

Study: Chest. 1997 Mar;111(3):537-43. PMID: 9118684

S1 Q3 T3 Pattern Edit 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 Edit Sensitivity = 22%

Study: Chest. 1997 Mar;111(3):537-43. PMID: 9118684