Pulmonary Embolism: The Daily PANCE Blueprint

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Pulmonary Embolism: The Daily PANCE Blueprint

A 58-year-old woman presents with sudden-onset pleuritic chest pain and dyspnea that began 2 hours ago. She returned yesterday from a 10-hour flight and takes an estrogen-containing contraceptive. Her heart rate is 112/min, respiratory rate 24/min, and oxygen saturation 91% on room air; blood pressure is 124/78 mm Hg. Her right calf is swollen and tender. Clinical suspicion for pulmonary embolism is high. Which of the following is the most appropriate initial diagnostic test to confirm the diagnosis?

A. D-dimer
B. Lower-extremity venous duplex ultrasound
C. Ventilation-perfusion (V/Q) scan
D. Invasive pulmonary angiography
E. CT pulmonary angiography

Answer and topic summary

The answer is E. CT pulmonary angiography.

In a hemodynamically stable patient with HIGH pretest probability of pulmonary embolism, CT pulmonary angiography (CTPA) is the best initial confirmatory test — it directly visualizes the emboli and is the imaging modality of choice. A D-dimer is only useful to rule OUT pulmonary embolism in low/intermediate-probability patients; with high pretest probability it should not be used, because a negative result cannot exclude the diagnosis. V/Q scanning is the alternative when CTPA is contraindicated (renal failure, contrast allergy, pregnancy). A positive lower-extremity ultrasound supports the diagnosis, but a negative study does not exclude pulmonary embolism. Invasive pulmonary angiography is the historical gold standard but is rarely needed.

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Covered under ⇒ PANCE Blueprint Pulmonary ⇒ Pulmonary Circulation ⇒ Pulmonary Embolism

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