Diagnostiek bij longembolie; de beste strategieën volgens de resultaten van een grote Nederlandse multicenterstudie

- The Dutch national guidelines for the diagnosis of patients with clinically suspected pulmonary embolism (from 1992 en 1998) are poorly followed in clinical practice, due especially to practical objections. A large multicentre trial to investigate the diagnostic accuracy of the available modalities and of recently developed techniques such as D-dimer determination, ^99mTc-gas-scintigraphy and spiral CT scanning was started in 1997.

- In the first phase, the diagnostic value was assessed of: spiral CT (sensitivity 69, specificity 84; sensitivity for segmental and larger pulmonary embolisms (PE) 86 and for subsegmental PE 21), ^99mTc-gas-ventilation scintigraphy (no improvement compared to conventional ventilation scintigraphy), D-dimer determination (sensitivity for segmental PE 93 and for subsegmental PE 53, specificity 63), clinical decision rules (in combination with D-dimer determination; sensitivity 100, specificity 11) and echography of the deep venous system (sensitivity 26 for segmental PE and 7 for subsegmental PE, specificity 97).

- In the second phase, the feasibility of two new potentially cost-effective diagnostic algorithms was evaluated on the basis of the results obtained in the first phase and data in the literature. In 631 patients, a clinical risk estimate was made and D-dimer determination was done, followed by a ventilation-perfusion scan and serial compression echography of the leg veins. An apparent recurrence of PE occurred in 6 of 466 patients in whom no PE had been found originally (1.3; 95 CI: 0.5-2.8). The average costs were € 812,– per patient. In 510 patients, a spiral CT followed by compression echography was performed. Recurrent PE occurred in 3 of 378 patients with initial normal tests (0.8; 95 CI: 0.2-2.3). The average costs were € 883,– per patient. A combination of both strategies can be cost-effective with a cost of € 674,– per patient (recurrence rate: 1,9).

- Both the strategy starting with a clinical-risk estimate and a D-dimer determination as well as the strategy consisting of spiral CT and serial echography were safe and cost-effective. According to the results of a survey of hospital directors, internists and pulmonologists, both are well accepted in clinical practice.

Ned Tijdschr Geneeskd 2005;149:568-76