PULMONARY EMBOLISM FAILURE RATE IN PATIENTS IN WHOM PULMONARY EMBOLISM WAS RULED OUT BY LOW AND INTERMEDIATE PROBABILITY BY THE REVISED GENEVA SCORE AND A NORMAL QUANTITATIVE D-DIMER TEST RESULT

Abstract Abstract 3186 Background Several clinical decision rules (CDRs) are available for the exclusion of acute pulmonary embolism (PE). This prospective multi-center study compared the safety and clinical utility of four CDRs (Wells rule, revised Geneva score, simplified Wells rule and simplified revised Geneva score) in excluding PE in combination with D-dimer testing. Methods Clinical probability of patients with suspected acute PE was assessed using a computerized based “black box”, which calculated all CDRs and indicated the next diagnostic step. A “PE unlikely” result according to all CDRs in combination with a normal D-dimer result excluded PE, while patients with “PE likely” according to at least one of the CDRs or an abnormal D-dimer result underwent CT-scanning. Patients in whom PE was excluded were followed for three months. Results 807 consecutive patients were included and PE prevalence was 23%. The number of patients categorized as “PE unlikely” ranged from 62% (simplified Wells rule) to 72% (Wells rule). Combined with a normal D-dimer level, the CDRs excluded PE in 22–24% of patients. The total failure rates of the CDR-D-dimer combinations were similar (1 failure, 0.5– 0.6%, upper 95% CI 2.9– 3.1%). Despite 30% of the patients had discordant CDR outcomes, PE was missed in none of the patients with discordant CDRs and a normal D-dimer result. Conclusions All four CDRs show similar safety and clinical utility for exclusion of acute PE in combination with a normal D-dimer level. With this prospective validation, the more straightforward simplified scores are ready for use in clinical practice. Disclosures: No relevant conflicts of interest to declare.

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The Simplified Geneva Score and the Utilization of the D-Dimer and Computerized Tomography for Assessing Pulmonary Embolism

Kansas Journal of Medicine ◽

10.17161/kjm.v4i4.11392 ◽

2011 ◽

Vol 4 (4) ◽

pp. 99-104

Author(s):

John H Park ◽

Cole R Spresser ◽

Jorge A Valdivia ◽

Michael J Khadavi ◽

Saikat Das ◽

...

Keyword(s):

Pulmonary Embolism ◽

Decision Rules ◽

Clinical Decision ◽

Pulmonary Emboli ◽

Clinical Decision Rules ◽

Diagnostic Decision ◽

Revised Geneva Score ◽

Effective Use ◽

Diagnostic Decision Making ◽

D Dimer

Background. Pulmonary embolism (PE) is clinically suspected in many patients who complain of shortness of breath or chest pain due to its nonspecific nature. The prevalence of PE, however, is low in this population. To assist physicians in diagnostic decision making, several clinical decision rules (CDR) have been developed. The appropriate use of these CDRs has been proven to decrease the need for expensive, time consuming, and invasive diagnostic imaging procedures. In this study, the appropriateness of D-dimer and CT usage was investigated to rule out pulmonary emboli based on the simplified Geneva score. Methods. A retrospective review was performed on 74 patients with a CT scan ordered through a pulmonary embolism (PE) protocol. Using clinical data, the patients were stratified into “unlikely” and “likely” groups for the presence of PE based on the simplification of the revised Geneva score. Scores of 0-2 were graded as “unlikely” and scores of 3 or greater were “likely.” Results. There were 45/74 (60.8%) patients in the “unlikely” group. Of these, 14/45 (31.1%) received a D-dimer; eight were normal and six elevated. Only one patient in the elevated group had evidence of a PE. Of the remaining 31(39.2%) patients in the “unlikely” group that did not receive a D-dimer, only one had a PE. The “likely” group consisted of 29 (39.2%) patients of whom six received a D-dimer. Three patients had a normal D-dimer and three had an elevated level. Neither of these two groups had a PE. Of the remaining 23 (60.8%) in the “likely” group who did not receive a D-dimer, six had a PE. Conclusions. Diagnosing pulmonary emboli using D-dimer levels and CT scans may be aided by clinical decision rules such as the simplified Geneva system. This process may lead to more effective use of medical resources.

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The Performance of the Original and Simplified Wells Scores in Combination with Age-Adjusted D-Dimer Testing in the Diagnostic Management of Pulmonary Embolism

Blood ◽

10.1182/blood.v128.22.2569.2569 ◽

2016 ◽

Vol 128 (22) ◽

pp. 2569-2569

Author(s):

Noémie Kraaijpoel ◽

Nick van Es ◽

Harry R Büller ◽

Frederikus A Klok ◽

Menno V Huisman ◽

...

Keyword(s):

Pulmonary Embolism ◽

Failure Rate ◽

Meta Analysis ◽

Ease Of Use ◽

Grant Support ◽

Diagnostic Management ◽

Wells Score ◽

Wells Rule ◽

Discriminatory Performance ◽

D Dimer

Abstract Background: Among patients with suspected pulmonary embolism (PE), imaging can be safely withheld in those with a 'PE unlikely' Wells score and a negative D-dimer. A simplification of the Wells score has been proposed to improve clinical applicability (Table 1), but its performance is less clear, in particular in combination with age-adjusted D-dimer testing. Objectives: To compare the performance of the original and simplified Wells scores alone and in combination with age-adjusted D-dimer testing. Methods: Individual patient data from 7,268 patients with clinically suspected PE enrolled in 6 prospective diagnostic management studies were used. The discriminatory performance, calibration, and diagnostic accuracy of the original and simplified Wells scores were evaluated. The efficiency and failure rate of both dichotomized scores combined with age-adjusted D-dimer testing were compared using a one-stage random effects meta-analysis. Efficiency was defined as the proportion of patients in whom PE could be considered excluded based on a 'PE unlikely' Wells score and a D-dimer below the age-adjusted treshold, defined as ≤500 µg/L in patients of 50 years or younger and the patient's age times 10 µg/L in those older than 50 years. The failure rate was defined as the proportion of patients subsequently diagnosed with symptomatic venous thromboembolism during 3-month follow-up. Results: The discriminatory performance of the original and simplified Wells scores was comparable (c-statistic 0.73 [95% CI 0.72-0.75] vs. 0.72 [95% CI 0.70-0.73]). When combined with age-adjusted D-dimer testing, the original and simplified Wells rules had comparable efficiency (33% [95% CI 25-42%] vs 30% [95% CI 21-40%]) and failure rates (0.9% [95% CI 0.6-1.5%] vs. 0.8% [95% CI 0.5-1.3%]). Conclusion: Among patients with suspected PE, the original and simplified Wells rules in combination with age-adjusted D-dimer testing have similar performance in ruling out the disease. Given its ease of use in clinical practice, the simplified Wells rule may be preferred. Disclosures Huisman: Boehringer Ingelheim Pharma GmbH & Co.KG: Other: Grant support; GlaxoSmithKline: Other: Grant support; Bayer HealthCare: Other: Grant support; Pfizer: Other: Grant support; Actelion: Other: Grant support.

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THE VALUE OF D‐DIMER TEST AND COMBINATION WITH WELLS SCORE, REVISED GENEVA SCORE IN DIAGNOSIS THE PULMONARY EMBOLISM IN PATIENTS WITH COPD EXACERBATIONS

Respirology ◽

10.1111/resp.13700_450 ◽

2019 ◽

Vol 24 (S2) ◽

pp. 238-238

Keyword(s):

Pulmonary Embolism ◽

Copd Exacerbations ◽

Wells Score ◽

Revised Geneva Score ◽

D Dimer

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Knowledge of the D-dimer test result influences clinical probability assessment of pulmonary embolism

Thrombosis Research ◽

10.1016/j.thromres.2010.07.008 ◽

2010 ◽

Vol 126 (4) ◽

pp. e271-e275 ◽

Cited By ~ 9

Author(s):

Renée A. Douma ◽

Jasper B.F. Kessels ◽

Harry R. Buller ◽

Victor E.A. Gerdes

Keyword(s):

Pulmonary Embolism ◽

Probability Assessment ◽

Clinical Probability ◽

Test Result ◽

D Dimer

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Effectiveness of Clinical Decision Tools in Predicting Pulmonary Embolism

Pulmonary Medicine ◽

10.1155/2021/8880893 ◽

2021 ◽

Vol 2021 ◽

pp. 1-5

Author(s):

Michael A. Simon ◽

Christopher Tan ◽

Patrick Hilden ◽

Lyle Gesner ◽

Barry Julius

Keyword(s):

Emergency Department ◽

Pulmonary Embolism ◽

Patient Population ◽

Clinical Decision ◽

Decision Tools ◽

Computed Tomographic ◽

The Common ◽

Revised Geneva Score ◽

High Index Of Suspicion ◽

D Dimer

Objective. The Wells criteria and revised Geneva score are two commonly used clinical decision tools (CDTs) developed to assist physicians in determining when computed tomographic angiograms (CTAs) should be performed to evaluate the high index of suspicion for pulmonary embolism (PE). Studies have shown varied accuracy in these CDTs in identifying PE, and we sought to determine their accuracy within our patient population. Methods. Patients admitted to the Emergency Department (ED) who received a CTA for suspected PE from 2019 Jun 1 to 2019 Aug 31 were identified. Two CDTSs, the Wells criteria and revised Geneva score, were calculated based on data available prior to CTA and using the common D-Dimer cutoff of >500 μg/L. We determined the association between confirmed PE and CDT values and determined the association between the D-Dimer result and PE. Results. 392 CTAs were identified with 48 (12.1%) positive PE cases. The Wells criteria and revised Geneva score were significantly associated with PE but failed to identify 12.5% and 70.4% of positive PE cases, respectively. Within our cohort, a D-Dimer cutoff of >300 μg/L was significantly associated with PE and captured 95.2% of PE cases. Conclusions. Both CDTs were significantly associated with PE but failed to identify PE in a significant number of cases, particularly the revised Geneva score. Alternative D-Dimer cutoffs may provide better accuracy in identifying PE cases.

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Safety and Efficiency of the YEARS Diagnostic Algorithm for Pregnant Patients with Clinically Suspected Acute Pulmonary Embolism —the Artemis Study

Blood ◽

10.1182/blood-2018-99-113336 ◽

2018 ◽

Vol 132 (Supplement 1) ◽

pp. 419-419

Author(s):

Liselotte M. Van Der Pol ◽

Cecile Tromeur ◽

Ingrid Bistervels ◽

Thomas van Bemmel ◽

Francis Couturaud ◽

...

Keyword(s):

Pulmonary Embolism ◽

Pregnant Women ◽

Failure Rate ◽

Acute Pulmonary Embolism ◽

Diagnostic Algorithm ◽

Ct Scanning ◽

Ct Scans ◽

Acute Pe ◽

D Dimer

Abstract Background Acute pulmonary embolism (PE) is the leading cause of maternal mortality in Western countries, accounting for 20 to 30% of all maternal deaths. Therefore, the threshold to test for PE during pregnancy is low. Because evidence regarding the safety of ruling out PE with clinical decision rules and D-dimer tests in pregnant women is unavailable, all women with a suspected PE need to undergo an imaging test, with potential harm to patient and fetus by exposure to ionizing radiation. In the present international, multicenter, prospective management study, we evaluated the safety and efficiency of the YEARS diagnostic algorithm for ruling out PE in pregnant patients with clinically suspected PE (Netherlands Trial Registry number 5913). YEARS is a simple diagnostic algorithm designed to reduce the number of required computed tomography (CT) scans in the diagnostic work-up of PE in non-pregnant patients, and was recently shown to be as safe as conventional algorithms but associated with a significant absolute 14% reduction in the number of CT scans (van der Hulle et al., Lancet 2017). Methods The Artemis study was performed in 11 Dutch hospitals, 8 French hospitals and 1 Irish hospital. Consecutive pregnant patients with suspected acute PE were included. Exclusion criteria were treatment with therapeutically dosed anticoagulants >24 hours or contraindications for CT. The YEARS algorithm was slightly adjusted for application during pregnancy (figure 1): in patients with signs of deep vein thrombosis (DVT), compression ultrasonography was obligatory before CT scanning was considered. In patients with proven DVT, anticoagulant treatment was initiated and no further diagnostic tests were undertaken. In patients with no YEARS items (Figure 1), a D-dimer threshold of <1.0 µg/ml was sufficient to rule out PE. In the remaining patients D-dimer threshold was <0.5 µg/mL. CT scanning was only performed in patients with a D-dimer level above the threshold. Anticoagulant therapy was withheld if PE was excluded. The primary safety endpoint was the occurrence of symptomatic venous thromboembolism during 3 months of follow-up, the primary efficiency endpoint was the proportion of patients in whom CTPA could be avoided. All safety endpoints were adjudicated by an independent committee. Assuming a 1.0% diagnostic failure rate and defining a maximum acceptable failure rate of 2.7%, a total study population of 472 patients was required (one-sided alpha 0.05, beta 80%). Results and conclusion: The last patient was included in May 2018. At baseline, 48% of pregnant women with suspected acute PE had no YEARS item and a D-dimer threshold of 1.0 µg/mL was applied. A total of 42% had a D-dimer level below the relevant threshold and were managed without CT scanning. Follow-up and endpoint adjudication was not completed at the abstract submission deadline; full study results will be presented at the ASH meeting. Disclosures Couturaud: Pfizer: Research Funding; Bayer: Honoraria, Other: Travel Support; AstraZeneca: Honoraria; Actelion: Other: Travel Support; Intermune: Other: Travel Support; Leo Pharma: Other: Travel Support; Daiichi Sankyo: Other: Travel Support.

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Application of a decision rule and a D-dimer assay in the diagnosis of pulmonary embolism

Thrombosis and Haemostasis ◽

10.1160/th08-09-0564 ◽

2010 ◽

Vol 103 (04) ◽

pp. 849-854 ◽

Cited By ~ 12

Author(s):

Renee Douma ◽

Alessandro Squizzato ◽

Maaike Sohne ◽

Harry Buller ◽

Victor Gerdes ◽

...

Keyword(s):

Pulmonary Embolism ◽

Decision Rule ◽

Response Rate ◽

Clinical Information ◽

Clinical Decision ◽

Questionnaire Response ◽

Clinical Probability ◽

Current Guidelines ◽

Test Result ◽

D Dimer

SummaryCurrent strategies for diagnosing pulmonary embolism (PE) include a clinical decision rule (CDR), followed by a D-dimer assay in patients with an unlikely clinical probability. We assessed the implementation of the current guidelines for the diagnosis of PE. A first questionnaire was sent to internists and pulmonologists to assess the proportion of physicians that adequately applied the guidelines. Two versions of a second questionnaire were sent presenting five hypothetical cases of which in two cases with an intermediate clinical probability an abnormal D-dimer test result was added to one version. We assessed the variation of the CDR and compared the proportions of a likely clinical probability between the two versions. A total of 65 physicians responded to the first questionnaire (response rate 75%). Half of the physicians (N=29; 46%) indicated that they use a CDR in all patients and 22 physicians (45%) indicated that they review the D-dimer result after they examined patients. Sixty-two physicians responded on the second questionnaire (response rate 36%). A shift was observed from an unlikely to a likely probability when an abnormal D-dimer test result was added to the clinical information (22% to 41%; p=0.22 and 26% to 50%; p<0.05). Our findings indicate that physicians do not use the guidelines for diagnosis of PE consistently. Furthermore, the knowledge of an abnormal D-dimer test result before seeing the patient leads to a higher CDR score. Physicians should therefore first examine patients before taking note of the D-dimer test result.

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Elderly Population with COVID-19 and the Accuracy of Clinical Scales and D-Dimer for Pulmonary Embolism: The OCTA-COVID Study

Journal of Clinical Medicine ◽

10.3390/jcm10225433 ◽

2021 ◽

Vol 10 (22) ◽

pp. 5433

Author(s):

Maribel Quezada-Feijoo ◽

Mónica Ramos ◽

Isabel Lozano-Montoya ◽

Mónica Sarró ◽

Verónica Cabo Muiños ◽

...

Keyword(s):

Pulmonary Embolism ◽

Area Under The Curve ◽

Scoring Systems ◽

Cutoff Point ◽

Study Cohort ◽

Clinical Scales ◽

Clinical Probability ◽

Wells Score ◽

Revised Geneva Score ◽

D Dimer

Background: Elderly COVID-19 patients have a high risk of pulmonary embolism (PE), but factors that predict PE are unknown in this population. This study assessed the Wells and revised Geneva scoring systems as predictors of PE and their relationships with D-dimer (DD) in this population. Methods: This was a longitudinal, observational study that included patients ≥75 years old with COVID-19 and suspected PE. The performances of the Wells score, revised Geneva score and DD levels were assessed. The combinations of the DD level and the clinical scales were evaluated using positive rules for higher specificity. Results: Among 305 patients included in the OCTA-COVID study cohort, 50 had suspected PE based on computed tomography pulmonary arteriography (CTPA), and the prevalence was 5.6%. The frequencies of PE in the low-, intermediate- and high-probability categories were 5.9%, 88.2% and 5.9% for the Geneva model and 35.3%, 58.8% and 5.9% for the Wells model, respectively. The DD median was higher in the PE group (4.33 mg/L; interquartile range (IQR) 2.40–7.17) than in the no PE group (1.39 mg/L; IQR 1.01–2.75) (p < 0.001). The area under the curve (AUC) for DD was 0.789 (0.652–0.927). After changing the cutoff point for DD to 4.33 mg/L, the specificity increased from 42.5% to 93.9%. Conclusions: The cutoff point DD > 4.33 mg/L has an increased specificity, which can discriminate false positives. The addition of the DD and the clinical probability scales increases the specificity and negative predictive value, which helps to avoid unnecessary invasive tests in this population.

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