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PE Likely Investigation Pathway — EECC MCQ

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EasyPulmonary Vascular DiseasePE Likely Investigation PathwayEECC

A 45-year-old woman presents to the emergency department with acute dyspnoea and chest pain. She has a history of deep vein thrombosis 3 years ago. She is tachycardic (HR 115), tachypnoeic (RR 28), and has SpO₂ of 91% on air. Her Wells score is 7 (PE likely). What is the next investigation?

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Correct answer: A — CTPA (CT pulmonary angiography) — when clinical probability is 'PE likely' (Wells >4), CTPA should be performed directly without first checking D-dimer

The ESC 2019 PE Guidelines use a two-tier approach based on clinical probability: (1) PE unlikely (Wells ≤4): measure D-dimer — if negative, PE excluded; if positive, proceed to CTPA; (2) PE likely (Wells >4): proceed directly to CTPA without D-dimer (as D-dimer is expected to be positive and adds no useful information). This patient with Wells 7 should proceed directly to CTPA. Anticoagulation with LMWH or fondaparinux should be started while awaiting CTPA if clinical suspicion is high. V/Q scan is an alternative when CTPA is contraindicated (severe contrast allergy, CKD stage 4-5, pregnancy — lower radiation dose to breasts). CTPA has sensitivity >95% and specificity >97% for PE.

Reference: ESC (2019): Guidelines on Acute Pulmonary Embolism