From the Guidelines
This 35-year-old male with non-pleuritic chest pain, no risk factors for venous thromboembolism (VTE), normal oxygen saturation, and a normal heart rate has a low risk of pulmonary embolism (PE), and therefore, no immediate diagnostic testing for PE is warranted in this scenario. The clinical presentation of this patient aligns with a low probability of PE, as suggested by the most recent guidelines and studies, including the 2022 update from the Journal of the American College of Radiology 1. According to these guidelines, patients with a low clinical likelihood of PE and normal D-dimer results do not require PE imaging.
The patient's age, lack of risk factors for VTE, and normal vital signs all contribute to a low pretest probability of PE. The Wells score or PERC rule, validated clinical decision tools, would likely classify this patient as low risk, further supporting the notion that PE is unlikely 1. Common alternative causes for his chest pain might include musculoskeletal pain, gastroesophageal reflux disease, or anxiety. If clinical concern persists, a D-dimer test could be considered as an initial step, though it's often unnecessary in low-risk patients, as indicated by the American College of Physicians' best practice advice 1.
The physiological basis for this assessment is that PE typically presents with more concerning features such as tachycardia, hypoxemia, or pleuritic pain, particularly in patients with predisposing factors for clot formation. Given the patient's normal oxygen saturation and heart rate, along with the absence of pleuritic pain, the likelihood of PE is further diminished. Therefore, alternative diagnoses should be considered and evaluated accordingly, prioritizing the patient's quality of life and minimizing unnecessary testing and potential harm.
From the Research
Patient Profile
- Age: 35 years
- Sex: Male
- Symptoms: Non-pleuritic chest pain
- Risk factors for VTE: None
- Oxygen saturation: Normal
- Heart rate: Normal
Risk of Pulmonary Embolism (PE)
- The patient's profile suggests a low risk of PE, as they have no risk factors for VTE and normal oxygen saturation and heart rate 2, 3.
- However, the presence of non-pleuritic chest pain requires further evaluation to rule out PE 4.
- A D-dimer test can be used to help diagnose PE, but a negative result does not completely rule out the condition, especially if the patient has a high clinical probability of PE 5, 6.
- The Wells score or modified Wells score can be used to estimate the pre-test probability of PE, which can guide further testing and management 2, 3.
Diagnostic Approach
- If the patient has a low pre-test probability of PE and a negative D-dimer test, an alternative diagnosis should be considered, and further testing for PE may not be necessary 2, 6.
- However, if the patient has a moderate or high pre-test probability of PE, or if the D-dimer test is positive, further imaging studies such as computed tomography pulmonary angiography (CTPA) may be necessary to confirm the diagnosis 3, 4.
- The use of CTPA should be guided by clinical judgment and adherence to current guidelines to avoid overuse and minimize radiation exposure 3.