Importance of clinical assessment in selecting patients for pulmonary arteriography.

A recent reporti indicates an exceedingly high incidence rate (73 percent) of negative pulmonary arteriograms in patients with suspected pulmonary embolism. All of these patients had a “suitable clinical history,” hypoxemia and positive perfusion scans. In view of this apparent failure of clinical evaluation and noninvasive tests, it was concluded that overdiagnosis and overtreatment can be avoided only with wide use of pulmonary arteriography. The clear implication was that pulmonary embolism can be neither identified with reasonable certainty nor excluded in a vast majority of suspected instances unless pulmonary arteriograms are performed. It was suggested that “the emperor has no clothes.” We strongly disagree. We believe that the clinical manifestations of pulmonary embolism are now sufficiently recognizable to permit a correct presumptive diagnosis or a correct exclusion in a large majority of patients. We believe that an incidence rate of 70 to 80 percent of negative pulmonary arteriograms in patients with suspected pulmonary embolism reflects a serious underevaluation of the important clinical manifestations of pulmonary embolism. Although the signs and symptoms of pulmonary embolism are nonspecific, the manifestations, when considered as a group, form a set of syndromes that are strongly suggestive. Conversely, the absence of key clinical features is strong evidence for exclusion. The purpose of this communication is to suggest that the clinical manifestations, when carefully and fully evaluated, are sufficiently