10 Choosing Wisely Recommendations for Hospitalists
8 Society of Nuclear Medicine and Molecular Imaging (SNMMI)
Recommendation: Avoid using a CT angiogram to diagnose pulmonary embolism (PE) in young women with a normal chest radiograph; consider a radionuclide lung (V/Q) study instead.
Hospitalists should be knowledgeable of the diagnostic options that will result in the lowest radiation exposure when evaluating young women for PE.
"When a chest radiograph is normal or nearly normal, a computed tomography angiogram or a V/Q lung scan can be used to evaluate these patients. While both exams have low radiation exposure, the V/Q lung scan results in less radiation to the breast tissue," says society president Gary L. Dillehay, MD, FACNM, FACR, professor of radiology at Northwestern Memorial Hospital in Chicago. "Recent literature cites concerns over radiation exposure from mammography; therefore, reducing radiation exposure to breast tissue, when evaluating patients for suspected PE, is desirable."
Hospitalists might have difficulty obtaining a V/Q lung scan when nuclear medicine departments are closed.
"The caveat is that CT scans are much more readily available," Dr. Auron says. In addition, a CT scan provides additional information. But unless the differential diagnosis is much higher for PE than other possibilities, just having a V/Q scan should suffice.
Hospitalists could help implement protocols for chest pain evaluation in premenopausal women by having checklists for risk factors for coronary artery disease, connective tissue disease (essentially aortic dissection), and VTE (e.g. Wells and Geneva scores, use of oral contraceptives, smoking), Dr. Auron says. If the diagnostic branch supports the risk of PE, then nuclear imaging should be available.
"A reasonable way to justify the increased availability of the nuclear medicine department would be to document the number of CT chest scans done after hours in patients who would have instead had a V/Q scan," he says.