CE-MRA in the primary diagnosis of pulmonary embolism
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Each day clinicians deal with patients that have chest pain. Using a combination of clinical history, an electrocardiogram, appropriate laboratory data, pertinent physical findings, clinical decision rules and clinical judgment leads to a likely group of differential diagnoses.1, 2 The many algorithms for evaluating and managing chest pain are beyond the scope of this article.3 The purpose of this article is to discuss the specific clinical scenarios that may benefit from the use of contrast-enhanced pulmonary magnetic resonance angiography (CE-MRA) for the primary diagnosis of pulmonary embolism (PE), the current outcomes data regarding the effectiveness of this test and how to overcome the administrative barriers to implementing this test in a busy academic practice.

The incidence of PE is approximately 1:1,000 in the healthy population.3 The death rate from this disease is 10-30% within one month of diagnosis.4 For hospitalized patients, annual deaths attributed to PE can be as high as 5%.5 The immediate post-trauma patient, specifically, represents a group in which this disease is often underdiagnosed.6

In the emergent setting, the three most concerning chest pain diagnoses are acute coronary syndrome, aortic dissection and pulmonary embolism. More so than the other two diagnoses, PE presentations can be highly variable, ranging from subtle findings to hemodynamic instability, often in the context of no known precipitant.7 Adding to this variable presentation is the fact that pulmonary arteries do not have pain fibers. The obstruction to the pulmonary arterial circuit coupled with the cardiopulmonary reserve of an individual patient determines the degree of desaturation, the increase in respiratory rate (dyspnea), and the extent of tachycardia that develops.