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Unsuspected and so undiagnosed pulmonary embolism (PE) is an important clinical problem and cause of death.1 Clinicians need to be always alert to the possibility of this treatable condition. Understanding the predictive value of routine tests is crucial if the diagnosis is not to be missed. A chest radiograph is usually the first imaging study to be performed in patients with chest pain or dyspnoea, regardless of the clinical suspicion of PE. Large studies of chest radiographs in patients with proven PE provide a basis for understanding just how much, or how little and why, the chest radiograph can contribute to the diagnosis of PE.
The chest radiograph is usually abnormal in patients with PE. In one review of 1063 patients with suspected PE, only 12% of those proven to have PE were found to have normal chest radiographs.2 The international cooperative study of the PE registry reported that only 24% of 2452 patients with acute PE had normal chest radiographs.1 A normal chest radiograph cannot, however, exclude PE.
Several abnormal radiographic signs are classically associated with PE, and …