p.17 抽出テキスト

4.11 Recommendations for diagnosis

Recommendations Classa Levelb

Suspected PE with haemodynamic instability In suspected high-risk PE, as indicated by the presence of haemodynamic instability, bedside echocardiography or emergency CTPA (depending on availability and clinical circumstances) is recommended for diagnosis.169 I C It is recommended that i.v. anticoagulation with UFH, including a weight-adjusted bolus injection, be initiated without delay in patients with suspected high-risk PE. I C Suspected PE without haemodynamic instability The use of validated criteria for diagnosing PE is recommended.12 I B Initiation of anticoagulation is recommended without delay in patients with high or intermediate clinical probability of PE while diagnostic workup is in progress. I C Clinical evaluation It is recommended that the diagnostic strategy be based on clinical probability, assessed either by clinical judgement or by a validated prediction rule.89,91,92,103,134,170172 I A D-dimer Plasma D-dimer measurement, preferably using a highly sensitive assay, is recommended in outpatients/emergency department patients with low or intermediate clinical probability, or those that are PE-unlikely, to reduce the need for unnecessary imaging and irradiation.101103,122,164,171,173,174 I A As an alternative to the fixed D-dimer cut-off, a negative D-dimer test using an age-adjusted cut-off (age  10 mg/L, in patients aged >50 years) should be considered for excluding PE in patients with low or intermediate clinical probability, or those that are PE-unlikely.106 IIa B As an alternative to the fixed or age-adjusted D-dimer cut-off, D-dimer levels adapted to clinical probabilityc should be considered to exclude PE.107 IIa B D-dimer measurement is not recommended in patients with high clinical probability, as a normal result does not safely exclude PE, even when using a highly sensitive assay.175,176 III A CTPA It is recommended to reject the diagnosis of PE (without further testing) if CTPA is normal in a patient with low or intermediate clinical probability, or who is PE-unlikely.101,122,164,171 I A It is recommended to accept the diagnosis of PE (without further testing) if CTPA shows a segmental or more proximal filling defect in a patient with intermediate or high clinical probability.115 I B It should be considered to reject the diagnosis of PE (without further testing) if CTPA is normal in a patient with high clinical probability or who is PE-likely.171 IIa B Further imaging tests to confirm PE may be considered in cases of isolated subsegmental filling defects.115 IIb C CT venography is not recommended as an adjunct to CTPA.115,164 III B V/Q scintigraphy It is recommended to reject the diagnosis of PE (without further testing) if the perfusion lung scan is normal.75,122,134,174 I A It should be considered to accept that the diagnosis of PE (without further testing) if the V/Q scan yields high probability for PE.134 IIa B A non-diagnostic V/Q scan should be considered as exclusion of PE when combined with a negative proximal CUS in patients with low clinical probability, or who are PE-unlikely.75,122,174 IIa B

Continued Downloaded from academic.oup.com/eurheartj/article/41/4/543/5556136 by guest on 07 October 2026