Approach to Suspected Acute Pulmonary Embolism: Should We Use Scoring Systems?

Marc Righini, MD; Grégoire Le Gal, MD, PhD; Henri Bounameaux, MD

|Disclosures

Semin Respir Crit Care Med. 2017;38(1):3-10. 

 

Abstract and Introduction

Abstract

Modern diagnostic strategies for pulmonary embolism diagnosis almost all rely on an initial assessment of the pretest probability. Clinical prediction rules are decision-making tools using combinations of easily available clinical predictors to define the probability of a disease. The assessment of the clinical probability of pulmonary embolism has an important impact on the diagnostic strategy and on therapeutic management. Clinical prediction rules provide accurate and reproducible estimates of clinical probability. They should be derived and validated following strict methodological standards. The use of clinical prediction rules should be encouraged, since their implementation in local guidelines for pulmonary embolism diagnosis has been shown to improve patients' outcomes.

Introduction

Pulmonary embolism (PE) is the third cause of mortality by cardiovascular disease after coronary artery disease and stroke. In Western countries, it remains one of the leading causes of death in the puerperium and the postoperative period. It has been estimated that over one million venous thromboembolic (VTE) events or deaths occur each year in six large European countries, with three-quarters of the VTE-related deaths being from hospital-acquired VTE, which is, therefore, a major health concern.[1] Nonetheless, PE is difficult to diagnose because of protean clinical manifestations and poor sensitivity and specificity of symptoms and signs. Therefore, it is still underdiagnosed and up to 80% of pulmonary emboli found at autopsy have not been suspected ante mortem, a proportion which has not decreased in the last 40 years.[2] However, considerable progress has been made in the workup of patients with clinically suspected PE, which is based on the sequential use of pretest clinical probability, plasma D-dimer measurement, and computed tomography pulmonary angiography (CTPA).[3] These different diagnostic tests have been used in rational and cost-effective diagnostic strategies, and the assessment of clinical probability has been shown to improve patients' outcomes.[4]

 
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Table 1.  Clinical prediction rules for pulmonary embolism
Items Points
Original version Simplified version
Revised Geneva score21
   Age > 65 y 1 1
   Previous DVT or PE 3 1
   Surgery or fracture within 1 mo 2 1
   Active malignancy 2 1
   Unilateral lower limb pain 3 1
   Hemoptysis 2 1
   Heart rate
      75 to 94 bpm 3 1
       ≥ 95 bpm 5 2
   Pain on lower limb deep vein palpation and unilateral edema 4 1
   Clinical probability
   Three-level score
   Low 0–3 0–1
      Intermediate 4–10 2–4
      High ≥ 11 ≥ 5
   Two-level score
   PE unlikely 0–5 0–2
   PE likely ≥ 6 ≥ 3
Wells score22
   Previous PE or DVT 1.5 1
   Surgery or immobilization within the past 4 wk 1.5 1
   Cancer 1 1
   Hemoptysis 1 1
   Heart rate > 100 bpm 1.5 1
   Clinical signs of DVT 3 1
   Alternative diagnosis less likely than PE 3 1
   Clinical probability
      Three-level probability score
   Low 0–1 NA
      Intermediate 2–6 NA
      High ≥ 7 NA
   Two-level probability score
      PE unlikely 0–4 0–1
      PE likely >4 ≥ 2

Abbreviations: bpm, beats per minute; DVT, deep vein thrombosis; PE, pulmonary embolism.

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Authors and Disclosures

Marc Righini, MD1, Grégoire Le Gal, MD, PhD2 and Henri Bounameaux, MD1

1Division of Angiology and Hemostasis, Department of Medical Specialties, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland
2Thrombosis Program, Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada

Address for correspondence
Marc Righini, MD, Division of Angiology and Hemostasis, Department of Medical Specialties, Geneva University Hospital and Faculty of Medicine, 4, rue Gabrielle-Perret-Gentil, CH-1211 Geneva 14, Switzerland (e-mail: Marc.Righini@hcuge.ch).

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