Why the study?
Acute breathlessness often reflects overlapping PE, HF, and ACS pathologies, and CTPA is frequently used without documented pretest probability assessments. This audit evaluated CTPA diagnostic yield against the RCR standard of ≥15% and described biomarker testing, imaging, and outcomes across the PE, HF, and ACS pathways.
Does the diagnostic yield of CTPA for suspected pulmonary embolism in patients referred to cardiology with acute breathlessness meet the Royal College of Radiologists standard of ≥15%, and how do biomarker results relate to imaging yields across the PE, HF, and ACS pathways?
Cohort (n=70)
No
Does the diagnostic yield of CTPA for suspected pulmonary embolism in patients referred to cardiology with acute breathlessness meet the Royal College of Radiologists standard of ≥15%, and how do biomarker results relate to imaging yields across the PE, HF, and ACS pathways?
Answers are grounded in this paper and cite their sources.
In patients referred to cardiology with acute breathlessness, overlapping biomarker and imaging pathways were common, while CTPA diagnostic yield (13.0%) and pretest probability documentation (22.2%) fell below Royal College of Radiologists standards, highlighting the need for mandatory pretest probability documentation.
Background Breathlessness is a leading cause of emergency hospital attendances, and its multifactorial nature often reflects overlapping cardiopulmonary pathologies such as pulmonary embolism (PE), heart failure (HF), and acute coronary syndrome (ACS). Computed tomography pulmonary angiography (CTPA) is frequently used, often without documented pretest probability assessments. This audit primarily assessed the diagnostic yield of CTPA for suspected PE against the Royal College of Radiologists (RCR) standard of ≥15% and secondarily described biomarker testing, imaging, and outcomes across the PE, HF, and ACS pathways in patients referred to cardiology with acute breathlessness. Methods We conducted a retrospective audit of 70 adults referred to cardiology with breathlessness through the electronic patient record or multiprofessional team list (MPTL) referral systems at a district general hospital in the United Kingdom between March 1 and June 30, 2025. Biomarker testing for D-dimer, N-terminal pro-B-type natriuretic peptide (NT-proBNP), and high-sensitivity troponin I (hs-TnI), together with imaging and outcomes, was reviewed and described across the PE, HF, and ACS pathways, with diagnostic yields restricted to CTPA for suspected PE and coronary angiography for suspected ACS. Yields were reported with Wilson 95% CIs and compared using exploratory Fisher’s exact tests. Additional analyses examined biomarker concentrations by outcome and overlap in biomarker and imaging use. Results Seventy patients were included (median age, 69.5 years; 52.9% male). D-dimer, NT-proBNP, and hs-TnI were tested in 68.6%, 58.6%, and 81.4% of patients, respectively. Overall, seven of 54 CTPAs performed for suspected PE were positive (13.0%, 95% CI, 6.4-24.4), numerically below the RCR benchmark of ≥15%. A clinically relevant alternative diagnosis was reported in 44.4% (target, ≥50%), and pretest probability was documented in 22.2% (target, 100%). PE yield was 15.0% (6/40) among patients with an elevated D-dimer, 0% (0/4) among those with a normal D-dimer, and 10.0% (1/10) among those without D-dimer testing (p = 1.000 for both comparisons). Left ventricular systolic dysfunction (LVSD) was found on transthoracic echocardiography in 40.0% (8/20) of patients with elevated NT-proBNP, 23.1% (3/13) of those with non-elevated NT-proBNP, and 26.3% (5/19) of those without testing (p = 0.456 and p = 0.501, respectively). Of 47 patients with elevated hs-TnI, 10 (21.3%) underwent coronary angiography for suspected ACS, with percutaneous coronary intervention performed in four (40.0%). Overall, 29 of 57 patients tested (50.9%) had hs-TnI levels above the sex-specific 99th-percentile upper reference limit. Conclusions Cardiology-referred breathlessness frequently involved multiple biomarker and imaging pathways during the same admission. CTPA yield, alternative diagnosis rates, and pretest probability documentation fell below RCR standards. LVSD was more frequent with elevated NT-proBNP, although differences were not statistically significant. No hs-TnI comparison was possible because all patients undergoing angiography for suspected ACS had elevated levels. Given the small, single-center sample and selective imaging, these findings do not establish diagnostic accuracy or pathway effectiveness. Larger multicenter studies are needed. The findings support reviewing pretest probability documentation and investigation decisions, followed by reaudit against RCR standards.
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Mathews et al. (2026) conducted a cohort in Acute breathlessness (dyspnea) referred to cardiology (n=70). Computed tomography pulmonary angiography (CTPA) and biomarker testing (D-dimer, NT-proBNP, hs-TnI) vs. Royal College of Radiologists (RCR) audit standard (≥15% CTPA diagnostic yield for suspected PE) and normal or untested biomarker subgroups was evaluated on Diagnostic yield of CTPA performed for suspected pulmonary embolism (PE) (95% CI 6.4-24.4).
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