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ACR Appropriateness Criteria® Acute Chest Pain—Suspected Pulmonary Embolism

Bettmann, Michael A. MD; White, Richard D. MD; Woodard, Pamela K. MD; Abbara, Suhny MD; Atalay, Michael K. MD, PhD; Dorbala, Sharmila MD; Haramati, Linda B. MD, MS; Hendel, Robert C. MD; Martin, Edward T. III MD; Ryan, Thomas MD; Steiner, Robert M. MD

doi: 10.1097/RTI.0b013e31823efeb6
Web Exclusive Content—Appropriateness Criteria Review

Pulmonary embolism (PE) remains a common and important clinical condition that cannot be accurately diagnosed on the basis of signs, symptoms, and history alone. In the absence of high pretest probability and with a negative high-sensitivity D-dimer test, PE can be effectively excluded; in other situations, diagnostic imaging is necessary. The diagnosis of PE has been facilitated by technical advancements and multidetector computed tomography pulmonary angiography, which is the major diagnostic modality currently used. Ventilation and perfusion (V/Q) scans remain largely accurate and useful in certain settings. Lower-extremity ultrasound can substitute by demonstrating deep vein thrombosis; however, if negative, further studies to exclude PE are indicated. In all cases, correlation with the clinical status, particularly with risk factors, improves not only the accuracy of diagnostic imaging but also overall utilization. Other diagnostic tests have limited roles. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The development and review of the guidelines include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

*Department of Radiology, Wake Forest University School of Medicine, Winston-Salem, NC

Department of Radiology, Ohio State University Medical Center, Columbus, OH

Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, MS

§Department of Radiology, Massachusetts General Hospital, Boston, MA

Department of Diagnostic Imaging, The Warren Alpert School of Medicine at Brown University, Providence, RI

Department of Radiology, Brigham and Women’s Hospital, Society of Nuclear Medicine, Boston, MA

#Department of Radiology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY

**American College of Cardiology, Univeristy of Miami Miller School of Medicine, Outpatient Services Cardiovascular Division, Miami, FL

††American College of Cardiology, Oklahoma Heart Institute, Cardiovascular Magnetic Resonance Imaging, Tulsa, OK

‡‡American college of Cardiology, The Ohio State University Heart and Vascular Center, Columbus, OH

§§Department of Radiology, Temple University Health System, Philadelphia, PA

This article is a summary of the complete version of this topic, which is available on the ACR Website at www.acr.org/ac">www.acr.org/ac. Practitioners are encouraged to refer to the complete version.

The American College of Radiology (ACR) seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria® through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply society endorsement of the final document.

Robert M. Steiner, is an consultant and course director Educational Symposium Inc. and also consultant to Johnson and Johnson Co. Sharmila Dorbala, has a research grant from Astellas Pharma US Inc. and funded by NIH, a K23 grant. The other authors declare no conflicts of interest.

Reprints: Michael A. Bettmann, MD, Department of Quality & Safety, American College of Radiology, 1891 Preston White Dr., Reston, VA 20191 (e-mail: bettmann@wfubmc.edu).

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