Computed tomographic pulmonary angiography vs ventilation-perfusion lung scanning in patients with suspected pulmonary embolism - A Randomized controlled trial

Context Ventilation- perfusion ( (V) over dot/(Q) over dot.) lung scanning and computed tomographic pulmonary angiography ( CTPA) are widely used imaging procedures for the evaluation of patients with suspected pulmonary embolism. Ventilation- perfusion scanning has been largely replaced by CTPA in many centers despite limited comparative formal evaluations and concerns about CTPA's low sensitivity ( ie, chance of missing clinically important pulmonary embuli). Objectives To determine whether CTPA may be relied upon as a safe alternative to (V) over dot /(Q) over dot scanning as the initial pulmonary imaging procedure for excluding the diagnosis of pulmonary embolism in acutely symptomatic patients. Design, Setting, and Participants Randomized, single- blinded noninferiority clinical trial performed at 4 Canadian and 1 US tertiary care centers between May 2001 and April 2005 and involving 1417 patients considered likely to have acute pulmonary embolism based on a Wells clinical model score of 4.5 or greater or a positive D- dimer assay result. Intervention Patients were randomized to undergo either (V) over dot /(Q) over dot scanning or CTPA. Patients in whom pulmonary embolism was considered excluded did not receive antithrombotic therapy and were followed up for a 3- month period. Main Outcome Measure The primary outcome was the subsequent development of symptomatic pulmonary embolism or proximal deep vein thrombosis in patients in whom pulmonary embolism had initially been excluded. Results Seven hundred one patients were randomized to CTPA and 716 to (V) over dot/(Q) over dot scanning. Of these, 133 patients ( 19.2%) in the CTPA group vs 101 ( 14.2%) in the (V) over dot/(Q) over dot scan group were diagnosed as having pulmonary embolism in the initial evaluation period ( difference, 5.0%; 95% confidence interval [ CI], 1.1% to 8.9%) and were treated with anticoagulant therapy. Of those in whom pulmonary embolism was considered excluded, 2 of 561 patients ( 0.4%) randomized to CTPA vs 6 of 611 patients ( 1.0%) undergoing (V) over dot/(Q) over dot scanning developed venous thromboembolism in follow- up ( difference, - 0.6%; 95% CI, - 1.6% to 0.3%) including one patient with fatal pulmonary embolism in the (V) over dot/(Q) over dot group. Conclusions In this study, CTPA was not inferior to (V) over dot/(Q) over dot scanning in ruling out pulmonary embolism. However, significantly more patients were diagnosed with pulmonary embolism using the CTPA approach. Further research is required to determine whether all pulmonary emboli detected by CTPA should be managed with anticoagulant therapy.