Pulmonary Embolism??

[Anxious01]

Dr,

I am a highly anxious 25 year old male in good health, other than some severe acid reflux and asthma. For the past several months, I have been experencing this tight squeezing sensation in my left chest area. It moves from the middle of my chest, to the left of my pec. I do some flying for work, no flights over 5 hours, and have become extremely paranoid about having a PE. I have had a stress test, an echocardiogram, and an stress echo all which come back normal. I had a CTA done on 1/15 that was normal as well.

A week ago, I woke up with chills and a racing heart beat. I have been short of breath all this time, and I feel as if I cannot get a full breath of air in my left lung. My back feels extremely tight, and I feel as if i have to wiggle around to get a full breath in to fill my lungs. I had another CTA done on 3/18 which came back normal as well. I just got back yesterday from another flight, and am again freaked out about a PE.

Is there any reason for concern? They did a D Dimer on 3/18 that was 1.6.

Thanks!

[Anxious01]

Thanks Doc! I appreciate your time and response!

[David Tinkelman, M.D.]

Your concern is understandable.  I assume that your reference CTA is shorthand for CTPA (Computed Tomography with Pulmonary Angiography).  There is an extensive database now confirming the validity of  a negative CT pulmonary angiogram for the exclusion of significant PE. Meta-analysis of studies including a variety of techniques and scanner types and patient populations has revealed a Negative Predictive Value (NPV) of greater than 98%.  This implies that a negative or normal test will be truly negative nearly all the time. This is about as good as such testing ever gets.  You have just had two tests and that should be very reassuring that you have not had PE.  If still in doubt, you might want to ask your doctors about other established means of ruling-out the diagnosis of PE.  Among these is the use of clinical probability testing.  That is how likely is a person, who meets or does not meet well defined clinical criteria, to have had a PE.

Establishing  clinical probability by noninvasive testing has become an important step in diagnosis and treatment strategies. Two comprehensive studies, Prospective Investigation of Pulmonary Embolism Diagnosis and Prospective Investigative Study of Acute Pulmonary Embolism Diagnosis  highlight the importance of clinical probability assessment

in patients with suspected PE. Clinical probability assessment in the Prospective Investigation of Pulmonary Embolism Diagnosis study was standard, sometime ago.  . With this scoring system, 66.7% of the patients in the high probability group, 20.5% of the patients in the intermediate- probability group, and 3.6% of the patients in the low-probability group were diagnosed with PE [13].

It could be most reassuring if all the additional accumulated evidence supported your not having had a PE.  But, at some point, being practical means engaging in no further testing.  It is all too easy for a person to become fixated on a diagnosis, especially since the symptoms experienced are very real and consistent with the diagnosis in question.  This phenomenon is compounded in an individual who suffers from acute and/or chronic anxiety.

The ECHO studies would effectively rule out cardiac disease.  The other thing then would be to simply rule-out non-PE lung disease.  The normal CT scan of your lungs goes a long way toward that.  Pulmonary Function Tests (PFT’s) and an exercise study with arterial blood gas determinations, if normal, would rule out other lung disease, with a high degree of certainty.

At that point, it would not be unreasonable to look to anxiety, possibly with Panic Disorder, as the cause of your symptoms.

Good luck