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Abstract
Background. Computed tomography pulmonary angiography (CTPA) is the diagnostic reference standard for acute pulmonary embolism (PE), but overuse exposes patients to ionising radiation and iodinated contrast and increases service demand. Guidance recommends pretest-probability assessment (Wells score) and age-adjusted D-dimer testing before CTPA; the Royal College of Radiologists (RCR) considers a diagnostic yield of 15–35% acceptable.
Objective. To determine the diagnostic yield and negative rate of CTPA for clinically suspected acute PE at a single tertiary centre and to identify independent predictors of a negative scan.
Methods. A retrospective single-centre observational audit (January 2022 through December 2024, 36 months) was reported in accordance with the STROBE statement. Adults aged 18 years or older undergoing CTPA for suspected acute PE were included; the final CTPA report served as the reference standard. Multivariable logistic regression identified independent predictors of a negative scan.
Results. Of 1,184 studies screened, 948 formed the analytic cohort; 162 (17.1%, 95% CI 14.8–19.7%) were positive, giving a negative rate of 82.9%. Independent predictors of a negative CTPA were D-dimer below the age-adjusted threshold (aOR 9.42), absence of all PERC criteria in patients younger than 50 (aOR 5.71), Wells ≤ 4 (aOR 3.18), pre-existing COPD (aOR 2.34), and outpatient origin (aOR 2.05). The Wells score was documented in only 31.8% of requests.
Conclusions. The CTPA yield lay at the lower end of the RCR acceptable range and concentrated in patients investigated below the discriminatory pretest-probability and D-dimer thresholds, identifying actionable targets for a structured request-pathway intervention.
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Copyright (c) 2026 Sarah Ghaleb Shat
This work is licensed under a Creative Commons Attribution 4.0 International License.
References
- Wendelboe AM, Raskob GE. Global burden of thrombosis: epidemiologic aspects. Circ Res. 2016;118(9):1340–1347. doi: 10.1161/CIRCRESAHA.115.306841.
- Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J. 2020;41(4):543–603. doi: 10.1093/eurheartj/ehz405.
- Stein PD, Fowler SE, Goodman LR, Gottschalk A, Hales CA, Hull RD, et al. Multidetector computed tomography for acute pulmonary embolism. N Engl J Med. 2006;354(22):2317–2327. doi: 10.1056/NEJMoa052367.
- Walen S, Damoiseaux RA, Uil SM, van den Berg JW. Diagnostic yield of CT thorax angiography in patients suspected of pulmonary embolism: independent predictors and protocol adherence. Insights Imaging. 2014;5(2):231–236. doi: 10.1007/s13244-014-0319-3.
- Royal College of Radiologists. iRefer: Making the best use of clinical radiology. 8th ed. London: RCR; 2017.
- National Institute for Health and Care Excellence. Venous thromboembolic diseases: diagnosis, management and thrombophilia testing (NG158). London: NICE; 2020.
- Akhtar R, Rehman A, Tahir M, Mehmood A, Sarwar B, Shazlee MK. Computed tomography pulmonary angiography (CTPA) utilization in suspected pulmonary embolism patients based on age-adjusted D-dimer thresholds and pulmonary embolism rule-out criteria (PERC) score: a retrospective analysis. Cureus. 2025;17(3):e58982. doi: 10.7759/cureus.58982.
- Eshmawey S, Younis I, Khan R, Mohammed S. Appropriateness of CT pulmonary angiography requests at Croydon University Hospital: an audit. Cureus. 2025;17(10):e74212. doi: 10.7759/cureus.74212.
- von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP; STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet. 2007;370(9596):1453–1457. doi: 10.1016/S0140-6736(07)61602-X.
- Hendriksen JM, Geersing GJ, Lucassen WA, Erkens PM, Stoffers HE, van Weert HC, et al. Diagnostic yield of CT thorax angiography in patients suspected of pulmonary embolism: independent predictors and protocol adherence. Insights Imaging. 2014;5(2):231–236. doi: 10.1007/s13244-014-0317-5.
- Walen S, de Boer E, Edens MA, van der Worp CA, Damoiseaux RA, Lasonder E, et al. Mandatory adherence to diagnostic protocol increases the yield of CTPA for pulmonary embolism. Insights Imaging. 2016;7(5):727–734. doi: 10.1007/s13244-016-0509-2.
- Righini M, Van Es J, Den Exter PL, Roy PM, Verschuren F, Ghuysen A, et al. Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism: the ADJUST-PE study. JAMA. 2014;311(11):1117–1124. doi: 10.1001/jama.2014.2135.
- van der Hulle T, Cheung WY, Kooij S, Beenen LFM, van Bemmel T, van Es J, et al. Simplified diagnostic management of suspected pulmonary embolism (the YEARS study): a prospective, multicentre, cohort study. Lancet. 2017;390(10091):289–297. doi: 10.1016/S0140-6736(17)30885-1.
- Wells PS, Anderson DR, Rodger M, Stiell I, Dreyer JF, Barnes D, et al. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and D-dimer. Ann Intern Med. 2001;135(2):98–107. doi: 10.7326/0003-4819-135-2-200107170-00010.
- Le Gal G, Righini M, Roy PM, Sanchez O, Aujesky D, Bounameaux H, et al. Prediction of pulmonary embolism in the emergency department: the revised Geneva score. Ann Intern Med. 2006;144(3):165–171. doi: 10.7326/0003-4819-144-3-200602070-00004.
- Kline JA, Mitchell AM, Kabrhel C, Richman PB, Courtney DM. Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism. J Thromb Haemost. 2004;2(8):1247–1255. doi: 10.1111/j.1538-7836.2004.00790.x.
- Hutchinson BD, Navin P, Marom EM, Truong MT, Bruzzi JF. Overdiagnosis of pulmonary embolism by pulmonary CT angiography. AJR Am J Roentgenol. 2015;205(2):271–277. doi: 10.2214/AJR.14.13938.
- Le Pennec R, Le Mao R, Tromeur C, Lacut K, Couturaud F, Le Roux PY. Performance of clinical decision rules and D-dimer in the diagnosis of pulmonary embolism: an updated systematic review and meta-analysis. Thromb Res. 2024;233:166–175. doi: 10.1016/j.thromres.2023.12.001.
References
Wendelboe AM, Raskob GE. Global burden of thrombosis: epidemiologic aspects. Circ Res. 2016;118(9):1340–1347. doi: 10.1161/CIRCRESAHA.115.306841.
Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J. 2020;41(4):543–603. doi: 10.1093/eurheartj/ehz405.
Stein PD, Fowler SE, Goodman LR, Gottschalk A, Hales CA, Hull RD, et al. Multidetector computed tomography for acute pulmonary embolism. N Engl J Med. 2006;354(22):2317–2327. doi: 10.1056/NEJMoa052367.
Walen S, Damoiseaux RA, Uil SM, van den Berg JW. Diagnostic yield of CT thorax angiography in patients suspected of pulmonary embolism: independent predictors and protocol adherence. Insights Imaging. 2014;5(2):231–236. doi: 10.1007/s13244-014-0319-3.
Royal College of Radiologists. iRefer: Making the best use of clinical radiology. 8th ed. London: RCR; 2017.
National Institute for Health and Care Excellence. Venous thromboembolic diseases: diagnosis, management and thrombophilia testing (NG158). London: NICE; 2020.
Akhtar R, Rehman A, Tahir M, Mehmood A, Sarwar B, Shazlee MK. Computed tomography pulmonary angiography (CTPA) utilization in suspected pulmonary embolism patients based on age-adjusted D-dimer thresholds and pulmonary embolism rule-out criteria (PERC) score: a retrospective analysis. Cureus. 2025;17(3):e58982. doi: 10.7759/cureus.58982.
Eshmawey S, Younis I, Khan R, Mohammed S. Appropriateness of CT pulmonary angiography requests at Croydon University Hospital: an audit. Cureus. 2025;17(10):e74212. doi: 10.7759/cureus.74212.
von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP; STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet. 2007;370(9596):1453–1457. doi: 10.1016/S0140-6736(07)61602-X.
Hendriksen JM, Geersing GJ, Lucassen WA, Erkens PM, Stoffers HE, van Weert HC, et al. Diagnostic yield of CT thorax angiography in patients suspected of pulmonary embolism: independent predictors and protocol adherence. Insights Imaging. 2014;5(2):231–236. doi: 10.1007/s13244-014-0317-5.
Walen S, de Boer E, Edens MA, van der Worp CA, Damoiseaux RA, Lasonder E, et al. Mandatory adherence to diagnostic protocol increases the yield of CTPA for pulmonary embolism. Insights Imaging. 2016;7(5):727–734. doi: 10.1007/s13244-016-0509-2.
Righini M, Van Es J, Den Exter PL, Roy PM, Verschuren F, Ghuysen A, et al. Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism: the ADJUST-PE study. JAMA. 2014;311(11):1117–1124. doi: 10.1001/jama.2014.2135.
van der Hulle T, Cheung WY, Kooij S, Beenen LFM, van Bemmel T, van Es J, et al. Simplified diagnostic management of suspected pulmonary embolism (the YEARS study): a prospective, multicentre, cohort study. Lancet. 2017;390(10091):289–297. doi: 10.1016/S0140-6736(17)30885-1.
Wells PS, Anderson DR, Rodger M, Stiell I, Dreyer JF, Barnes D, et al. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and D-dimer. Ann Intern Med. 2001;135(2):98–107. doi: 10.7326/0003-4819-135-2-200107170-00010.
Le Gal G, Righini M, Roy PM, Sanchez O, Aujesky D, Bounameaux H, et al. Prediction of pulmonary embolism in the emergency department: the revised Geneva score. Ann Intern Med. 2006;144(3):165–171. doi: 10.7326/0003-4819-144-3-200602070-00004.
Kline JA, Mitchell AM, Kabrhel C, Richman PB, Courtney DM. Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism. J Thromb Haemost. 2004;2(8):1247–1255. doi: 10.1111/j.1538-7836.2004.00790.x.
Hutchinson BD, Navin P, Marom EM, Truong MT, Bruzzi JF. Overdiagnosis of pulmonary embolism by pulmonary CT angiography. AJR Am J Roentgenol. 2015;205(2):271–277. doi: 10.2214/AJR.14.13938.
Le Pennec R, Le Mao R, Tromeur C, Lacut K, Couturaud F, Le Roux PY. Performance of clinical decision rules and D-dimer in the diagnosis of pulmonary embolism: an updated systematic review and meta-analysis. Thromb Res. 2024;233:166–175. doi: 10.1016/j.thromres.2023.12.001.