• Maria José Fabiá Valls, Tom van der Hulle, Paul L den Exter, Inge C M Mos, Menno V Huisman, and Frederikus A Klok.
• Tom van der Hulle, MD, Department of Thrombosis and Hemostasis, Leiden University Medical Center, Albinusdreef 2, P. O. Box 9600, 2300 RC, Leiden, The Netherlands, Tel: +31 71 526 8132, Fax: +31 71 526 6868, E-mail: t.van_der_hulle@lumc.nl.
• Thromb. Haemost. 2015 Feb 1; 113 (2): 406-13.

AbstractDiagnostic management of suspected pulmonary embolism (PE) in patients with a history of venous thromboembolism (VTE) is complicated due to persistent abnormal D-dimer levels, residual embolic obstruction and higher clinical prediction rule (CPR) scores. We aimed to evaluate the safety and efficiency of the standard diagnostic algorithm consisting of a CPR, D-dimer test and computed tomography pulmonary angiography (CTPA) in this specific patient category. We performed a systematic literature search for prospective studies evaluating a diagnostic algorithm in consecutive patients with clinically suspected PE and a history of VTE. The VTE incidence rates during three-month follow-up and the number of indicated CTPAs were pooled using random effect models. Four studies concerning 1,286 patients were included with a pooled baseline PE prevalence of 36 % (95 % confidence interval [CI] 30-42). In only 217 patients (15 %; 95 %CI 11-20) PE could be excluded without CTPA. The three-month VTE incidence rate was 0.8 % (95 %CI 0.06-2.4) in patients managed without CTPA, 1.6 % (95 %CI 0.3-4.0) in patients in whom PE was excluded by CTPA and 1.4 % (95 %CI 0.6-2.7) overall. In the pooled studies, PE was safely excluded in patients with a history of VTE based on a CPR followed by a D-dimer test and/or CTPA, although the efficiency of the algorithm is relatively low compared to patients without a history of VTE.

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