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We identified 13 accuracy studies and one prospective outcome study. Eleven diagnostic accuracy studies were deemed at high risk of bias in at least two of the four domains of QUADAS-2 evaluation and a further two studies raised concerns regarding the applicability of results, precluding the meta-analysis for accuracy indices. The only prospective cohort study demonstrated critical risk of bias. Although V/Q SPECT has been widely implemented in daily clinical practice, the exact diagnostic performance of V/Q SPECT for PE is still unknow