Doubts and certainness in diagnosis of pulmonary embolism in the elderly

We have read with much interest the article of Punukollu et al. [1] recently published in your Journal and focused on differences in clinical presentation and treatment of pulmonary embolism (PE) in elderly compared with younger patients. This article arises important reflections on clinical picture and diagnostic approach to PE in the elderly that it should be important to highlight. Diagnosis of PE in fact is difficult in the elderly because of the nonspecificity of the clinical picture and the instrumental and laboratory tests, making this disease one of the main misdiagnoses in geriatric patients [2]. It is actually accepted in literature and widespread in guidelines [3–5] or recommendations [6] that suspicion of PE is based on history, analysis of risk factors for venous thromboembolic diseases, symptoms and signs together with first level instrumental examinations such as 12-leads electrocardiography (ECG), chest X-ray and blood arterial gas analysis (BGA). Once that clinical suspicion exists a clinical pre-test probability should be performed based on one of the available and validated test [7–10]. Low, moderate or high pre-test probability of PE should be integrated with immunoturbidimetric, simpli-RED or ELISA D-Dimer assay [11]. PE could reasonably be excluded when low pre-test probability and negative DDimer (