Internal and Emergency Medicine

, Volume 8, Issue 8, pp 695–702 | Cite as

Differential diagnosis of pulmonary embolism in outpatients with non-specific cardiopulmonary symptoms

  • Alessandro Squizzato
  • Davide Luciani
  • Andrea Rubboli
  • Leonardo Di Gennaro
  • Raffaele Landolfi
  • Carlo De Luca
  • Fernando Porro
  • Marco Moia
  • Sophie Testa
  • Davide Imberti
  • Guido Bertolini


Most cardiopulmonary diseases share at least one symptom with pulmonary embolism (PE). The aim of this study was to identify the most common acute causes of dyspnea, chest pain, fainting or palpitations, which diagnostic procedures were performed and whether clinicians investigate them appropriately. An Italian multicenter collaboration gathered 17,497 Emergency Department (ED) records of patients admitted from January 2007 to June 2007 in six hospitals. A block random sampling procedure was applied to select 800 hospitalised patients. Results of the overall 17,497 patients were obtained by weighting sampled cases according to the probability of the randomisation block variables in the whole population. The case-mix of enrolled patients was assessed in terms of cardiopulmonary symptoms, and the prevalence of acute disorders. The actual performance of procedures was compared with a measure of their accuracy as expected in the most common clinical presentations. PE occurred in less than 4% of patients with cardiopulmonary symptoms. Acute heart failure, pneumonia and chronic obstructive pulmonary disease exacerbation were the most likely diagnoses in patients with dyspnea. Acute myocardial infarction was present in roughly 10% of patients with chest pain. Atrial fibrillation was the prevalent diagnosis in patients with palpitations. Echocardiography, computed tomographic pulmonary angiography, perfusion lung scan, D-dimer test and B-type natriuretic peptide were performed less than expected from their accuracy. Diagnostic strategies, starting from non-specific symptoms and coping with the eventuality of PE, are likely to benefit from an increased awareness of the examination’s accuracy in discriminating among several competing hypotheses, rather than in testing the single PE suspicion.


Pulmonary embolism Differential diagnosis 



We are indebted to Simon Vittorio Mark Braham, Giorgi Pierfranceschi Matteo, Francesca Paganelli, Giovanni Giannelli, and Giuseppe Pigoli for both data collection and critical revision of final diagnoses. Sanofi-Aventis financially supported data collection

Conflict of interest



  1. 1.
    Kostantinides S (2008) Acute pulmonary embolism. N Engl J Med 359:2804–2813CrossRefGoogle Scholar
  2. 2.
    Miniati M, Prediletto R, Formichi B, Marini C, Di Ricco G, Tonelli L, Allescia G, Pistolesi M (1999) Accuracy of clinical assessment in the diagnosis of pulmonary embolism. Am J RespirCrit Care Med 159:864–871CrossRefGoogle Scholar
  3. 3.
    Nordstrom M, Lindblad B (1998) Autopsy-verified venous thromboembolism within a defined urban population—the city of Malmo, Sweden. APMIS 106:378–384PubMedCrossRefGoogle Scholar
  4. 4.
    Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P, Bengel F, Brady AJ, Ferreira D, Janssens U, Klepetko W, Mayer E, Remy-Jardin M, Bassand JP, ESC Committee for Practice Guidelines (CPG) (2008) Guidelines on the diagnosis and management of acute pulmonary embolism: the task force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC). Eur Heart J 29:2276–2315PubMedCrossRefGoogle Scholar
  5. 5.
    Corwin MT, Donohoo JH, Partridge R, Egglin TK, Mayo-Smith WW (2009) Do emergency physicians use serum D-dimer effectively to determine the need for CT when evaluating patients for pulmonary embolism? Review of 5, 344 consecutive patients. AJR Am J Roentgenol 192:1319–1323PubMedCrossRefGoogle Scholar
  6. 6.
    Costantino MM, Randall G, Gosselin M, Brandt M, Spinning K, Vegas CD (2008) CT angiography in the evaluation of acute pulmonary embolus. AJR Am J Roentgenol 191:471–474PubMedCrossRefGoogle Scholar
  7. 7.
    Fazel R, Krumholz HM, Wang Y, Ross JS, Chen J, Ting HH, Shah ND, Nasir K, Einstein AJ, Nallamothu BK (2009) Exposure to low-dose ionizing radiation from medical imaging procedures. N Engl J Med 361:849–857PubMedCrossRefGoogle Scholar
  8. 8.
    van Belle A, Büller HR, Huisman MV, Huisman PM, Kaasjager K, Kamphuisen PW, Kramer MH, Kruip MJ, Kwakkel-van Erp JM, Leebeek FW, Nijkeuter M, Prins MH, Sohne M, Tick LW, Christopher Study Investigators (2006) Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography. JAMA 295:172–179PubMedCrossRefGoogle Scholar
  9. 9.
    Righini M, Le Gal G, Aujesky D, Roy PM, Sanchez O, Verschuren F, Rutschmann O, Nonent M, Cornuz J, Thys F, Le Manach CP, Revel MP, Poletti PA, Meyer G, Mottier D, Perneger T, Bounameaux H, Perrier A (2008) Diagnosis of pulmonary embolism by multidetector CT alone or combined with venous ultrasonography of the leg: a randomised non-inferiority trial. Lancet 371:1343–1352PubMedCrossRefGoogle Scholar
  10. 10.
    Squizzato A, Micieli E, Galli M, Gibson N, Gerdes VE, Dentali F, Buller H, Ageno W, Venco A (2010) Diagnosis and management of venous thromboembolism: results of a survey on current clinical practice. Thromb Res 125:134–136PubMedCrossRefGoogle Scholar
  11. 11.
    Gibson NS, Douma RA, Squizzato A, Söhne M, Büller HR, Gerdes VE (2010) Application of a decision rule and a D-dimer assay in the diagnosis of pulmonary embolism. Thromb Haemost 103:849–854PubMedCrossRefGoogle Scholar
  12. 12.
    Luciani D, Marchesi M, Bertolini G (2003) The role of Bayesian Networks in the diagnosis of pulmonary embolism. J Thromb Haemost 4:698–707CrossRefGoogle Scholar
  13. 13.
    Luciani D, Cavuto S, Antiga L, Miniati M, Monti S, Pistolesi M, Bertolini G (2007) Bayes pulmonary embolism assisted diagnosis: a new expert system for clinical use. Emerg Med J 24:157–164PubMedCrossRefGoogle Scholar
  14. 14.
    Rothman KJ, Greenland S (2008) Modern epidemiology. Lippincott Williams & Wilkins, PhiladelphiaGoogle Scholar
  15. 15.
    Obuchowski NA, Goske MJ, Applegate KE (2001) Assessing physicians’ accuracy in diagnosing paediatric patients with acute abdominal pain: measuring accuracy for multiple diseases. Stat Med 20:3261–3278PubMedCrossRefGoogle Scholar
  16. 16.
    Pistolesi M, Pulmonary CT (2010) Angiography in patients suspected of having pulmonary embolism: case finding or screening procedure? Radiology 256:334–337PubMedCrossRefGoogle Scholar
  17. 17.
    Squizzato A, Ageno W (2006) What is the next step in D-dimer research? Education of physicians. Intern Emerg Med 1:165PubMedCrossRefGoogle Scholar
  18. 18.
    Moore CL, Molina AA, Lin H (2006) Ultrasonography in community emergency departments in the United States: access to ultrasonography performed by consultants and status of emergency physician-performed ultrasonography. Ann Emerg Med 47:147–153PubMedCrossRefGoogle Scholar
  19. 19.
    Adams ID, Chan M, Clifford PC, Cooke WM, Dallos V, de Dombal FT, Edwards MH, Hancock DM, Hewett DJ, McIntyre N et al (1986) Computer aided diagnosis of acute abdominal pain: a multicentre study. BMJ 293:800–804PubMedCrossRefGoogle Scholar
  20. 20.
    Erhardt L, Herlitz J, Bossaert L, Halinen M, Keltai M, Koster R, Marcassa C, Quinn T, van Weert H (2002) Task force on the management of chest pain. Eur Heart J 23:1153–1176PubMedCrossRefGoogle Scholar
  21. 21.
    Ray P, Birolleau S, Lefort Y, Becquemin MH, Beigelman C, Isnard R, Teixeira A, Arthaud M, Riou B, Boddaert J (2006) Acute respiratory failure in the elderly: etiology, emergency diagnosis and prognosis. Crit Care 10:R82PubMedCrossRefGoogle Scholar
  22. 22.
    Stein PD, Saltzman HA, Weg JG (1991) Clinical characteristics of patients with acute pulmonary embolism. Am J Cardiol 68:1723–1724PubMedCrossRefGoogle Scholar

Copyright information

© SIMI 2011

Authors and Affiliations

  • Alessandro Squizzato
    • 1
    • 9
  • Davide Luciani
    • 2
  • Andrea Rubboli
    • 3
  • Leonardo Di Gennaro
    • 4
  • Raffaele Landolfi
    • 4
  • Carlo De Luca
    • 5
  • Fernando Porro
    • 6
  • Marco Moia
    • 6
  • Sophie Testa
    • 7
  • Davide Imberti
    • 8
  • Guido Bertolini
    • 2
  1. 1.Department of Clinical Medicine, Research Center on Thromboembolic Disorders and Antithrombotic TherapiesUniversity of InsubriaVareseItaly
  2. 2.‘Mario Negri’ Institute for Pharmacological ResearchMilanItaly
  3. 3.Department of CardiologyOspedale MaggioreBolognaItaly
  4. 4.Haemostasis Research CenterCatholic UniversityRomeItaly
  5. 5.Department of RadiologyPoliclinico Sant′OrsolaMalpighiItaly
  6. 6.Ospedale Maggiore PoliclinicoMilanItaly
  7. 7.Thrombosis and Haemostasis CenterIstituti Ospitalieri di CremonaCremonaItaly
  8. 8.Department of Internal MedicinePiacenzaItaly
  9. 9.U.O. Medicina I, Ospedale di CircoloVareseItaly

Personalised recommendations