Simplifying Pulmonary Embolism Exclusion: Can One Clinical Question Safely Reduce Imaging?

Introduction: The Diagnostic Burden of Pulmonary Embolism

Pulmonary embolism (PE) remains one of the most challenging diagnoses in emergency medicine due to its non-specific clinical presentation. While computed tomography pulmonary angiography (CTPA) is the gold standard for diagnosis, its overuse carries significant risks, including radiation exposure, contrast-induced nephropathy, and the identification of clinically insignificant subsegmental emboli. To mitigate these risks, clinicians utilize D-dimer testing as a high-sensitivity, low-specificity screening tool. However, the traditional fixed threshold of 500 ng/mL often leads to unnecessary imaging, particularly in elderly patients or those with comorbid conditions that naturally elevate D-dimer levels.

Over the last decade, strategies such as age-adjusted thresholds and the YEARS algorithm have been introduced to increase the specificity of D-dimer testing. Despite their validated safety, adherence in busy clinical environments remains suboptimal due to the perceived complexity of multi-step decision rules. The study by Roussel et al., recently published in the Lancet Respiratory Medicine, explores whether a simplified, single-question approach can achieve similar safety while improving clinical utility.