**1.4.4 Perfusion scintigraphy**

Multiple studies have confirmed the benefit of perfusion scintigraphy as a non-invasive diagnostic procedure. It is necessary to combine perfusion scintigraphy with additional radiology imaging, like ventilation scintigraphy or chest X-ray. Various studies have confirmed that ventilation-perfusion scintigraphy has a positive predictive value of 88% (The PIOPED Investigators, 1990; Lee et al., 2005). The PISAPED study divided the probability of PE into 3 groups based on chest X-ray and perfusion scintigraphy results (Miniati et al., 1996). The sensitivity of perfusion scintigraphy is 92% with a positive predictive value of 92%. It has a negative predictive value of 88% with the specificity of 87%. Chronic pulmonary diseases caused perfusion defects may produce PE characteristic false results. To sum up, scintigraphy can help to exclude PE (error rate: 0.9%, confidence interval: 2.3%) (Kruip et al., 2003).

#### **1.4.5 Angiography**

According to the most recent PE guideline, the use of angiography is questionable as an invasive and hazardous intervention with mortality rate of 0.2%. The use of angiography is

In the presence of typical physical signs (dyspnoea, chest pain, syncope, tachypnea, tachycardia, cough, hemoptysis, signs of DVT, cyanosis, etc.) the diagnosis of PE is 90% reliable, although the severity of symptoms do not correlate with the actual illness. About 10% of high-risk cases are recognised by radiology imaging and considered to be non-high

Physical signs and symptoms: severe stabbing chest pain (52%), tachycardia (26%), cough (20%), cyanosis (15%) or paleness, increased perspiration, fever (38.5%), dyspnoea (with acute onset 80%), tachpnea (70%), hemoptysis (11%), mortal fear, syncope (19%), low blood pressure, haemodynamic failure with large vessel obstruction, arrhythmia (atrial or ventricular extrasystole, acute atrial fibrillation, flutter, etc.) (Miniati, Prediletto, Formichi,

According to the PISAPED study, occlusion of the hilar artery, oligaemia, wedge shaped infiltration against the pleural wall is detectable in 15-45% of all cases (Miniati, Prediletto, Formichi, Marini, Di Ricco, Tonelli, Allescia & Pistolesi, 1999b). In acute PE the typical X-ray signs can be weak or absent, but a single-sided elevation of the diaphragm, stripe-like atelectasis and the oedema of the affected pulmonary tissue (Westermark-sign) may develop with the prominence of the pulmonary artery. Occasionally unilateral pleural effusion is

The most common alterations are: sinus tachycardia, S1Q3T3 waveform (McGinn-White syndrome), acute P-pulmonale, negative T waves in V1-3 leads, incomplete or complete right bundle branch block, signs of RV strain, acute atrial fibrillation, atrio-ventricular conduction failures. Enlarged SISIISIII waveform develops after the dilatation of the right cavities causing the rotation of the cardiac axis. ECG signs are positive only in 50% of all patients (Torbicki et

Multiple studies have confirmed the benefit of perfusion scintigraphy as a non-invasive diagnostic procedure. It is necessary to combine perfusion scintigraphy with additional radiology imaging, like ventilation scintigraphy or chest X-ray. Various studies have confirmed that ventilation-perfusion scintigraphy has a positive predictive value of 88% (The PIOPED Investigators, 1990; Lee et al., 2005). The PISAPED study divided the probability of PE into 3 groups based on chest X-ray and perfusion scintigraphy results (Miniati et al., 1996). The sensitivity of perfusion scintigraphy is 92% with a positive predictive value of 92%. It has a negative predictive value of 88% with the specificity of 87%. Chronic pulmonary diseases caused perfusion defects may produce PE characteristic false results. To sum up, scintigraphy can help to exclude PE (error rate: 0.9%, confidence

According to the most recent PE guideline, the use of angiography is questionable as an invasive and hazardous intervention with mortality rate of 0.2%. The use of angiography is

al., 2000; Torbicki et al., 2008; Geibel et al., 2005; Rodger, Makropoulos, et al., 2000).

Marini, Di Ricco, Tonelli, Allescia & Pistolesi, 1999a; Stein & Henry, 1997).

present. Chest X-ray is useful to exclude certain diagnoses.

**1.4.1 Physical signs of PE** 

**1.4.2 Chest X-ray** 

risk according to physical symptoms.

**1.4.3 Electrocardiography (ECG)** 

**1.4.4 Perfusion scintigraphy** 

interval: 2.3%) (Kruip et al., 2003).

**1.4.5 Angiography** 

recommended in case of uncertain radiological imaging results. Non-invasive CT angiography offers comparable or better sensitivity (Wan et al., 2004; Agnelli et al., 2002).
