Background Computed tomographic pulmonary angiography (CTPA) may improve detection of life-threatening pulmonary embolism (PE), but this sensitive test may have a downside: overdiagnosis and overtreatment (finding clinically unimportant emboli and exposing patients to harms from unnecessary treatment). Methods To assess the impact of CTPA on national PE incidence, mortality, and treatment complications, we conducted a time trend analysis using the Nationwide Inpatient Sample and Multiple Cause-of-Death databases. We compared age-adjusted incidence, mortality, and treatment complications (in-hospital gastrointestinal tract or intracranial hemorrhage or secondary thrombocytopenia) of PE among US adults before (1993-1998) and after (1998-2006) CTPA was introduced. Results Pulmonary embolism incidence was unchanged before CTPA (P = .64) but increased substantially after CTPA (81% increase, from 62.1 to 112.3 per 100 000;P  Conclusions The introduction of CTPA was associated with changes consistent with overdiagnosis: rising incidence, minimal change in mortality, and lower case fatality. Better technology allows us to diagnose more emboli, but to minimize harms of overdiagnosis we must learn which ones matter.

https://jamanetwork.com/journals/jamainternalmedicine/articlepdf/227272/ioi15008_831_837.pdf

Time trends in pulmonary embolism in the United States: evidence of overdiagnosis.

Pulmonary embolism is an important clinical entity with considerable mortality despite advances in diagnosis and treatment. In the present article, the authors offer a comprehensive review focused mainly on epidemiology, risk factors, risk stratification, pathophysiological considerations and clinical presentation. Diagnosis based on assessment of clinical likelihood, electrocardiography, chest x-ray, D-dimer levels, markers of myocardial injury and overload, and blood gases is discussed in detail. Special attention is devoted to the clinical use of computed tomography, pulmonary angiography and echocardiography in the setting of pulmonary embolism.

Pulmonary embolism, part I: Epidemiology, risk factors and risk stratification, pathophysiology, clinical presentation, diagnosis and nonthrombotic pulmonary embolism.

#### Summary box

For decades clinicians have been taught that pulmonary embolism—defined by the National Institutes of Health as a “sudden blockage in a lung artery”1—always matters and to be vigilant because a missed embolism can be fatal.2 When a patient presents with shortness of breath, pleuritic chest pain, tachycardia, or signs of right heart strain, clinicians are trained to think “pulmonary embolism.” Because these symptoms and signs are neither sensitive nor specific, scoring systems (such as the Wells criteria) have been developed to help clinicians decide which patients to scan,3 although …

https://www.bmj.com/content/bmj/347/bmj.f3368.full.pdf

When a test is too good: how CT pulmonary angiograms find pulmonary emboli that do not need to be found

Early anticoagulation is associated with reduced mortality for acute pulmonary embolism

The value of ultrasound techniques in examination of the pleurae and lungs has been underestimated over recent decades. One explanation for this is the assumption that the ventilated lungs and the bones of the rib cage constitute impermeable obstacles to ultrasound. However, a variety of pathologies of the chest wall, pleurae and lungs result in altered tissue composition, providing substantially increased access and visibility for ultrasound examination. It is a great benefit that the pleurae and lungs can be non-invasively imaged repeatedly without discomfort or radiation exposure for the patient. Ultrasound is thus particularly valuable in follow-up of disease, differential diagnosis and detection of complications. Diagnostic and therapeutic interventions in patients with pathologic pleural and pulmonary findings can tolerably be performed under real-time ultrasound guidance. In this article, an updated overview is given presenting not only the benefits and indications, but also the limitations of pleural and pulmonary ultrasound.

Ultrasound of the pleurae and lungs.

Increased diagnosis of pulmonary embolism without a corresponding decline in mortality during the CT era.

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Increased diagnosis of pulmonary embolism without a corresponding decline in mortality during the CT era.