The majority of adults with chest pain and/or dyspnea do not have a pulmonary embolism (PE). There is strong evidence that in patients with low pre-test probability as determined by a clinical prediction rule (e.g., Wells score), a negative highly sensitive D-dimer assay effectively excludes clinically important PE. Furthermore, there are potential harms to performing CT pulmonary angiography (CTPA) or ventilation-perfusion (V/Q) scanning, including exposure to ionizing radiation, adverse events due to the administration of intravenous contrast, and identification of clinically insignificant PE leading to inappropriate anticoagulation. However, physicians should exercise clinical judgement in populations in whom this two-step algorithm has not been validated (e.g., pregnant patients).
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