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

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


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

In This Article

Abstract and Introduction


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.


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]