Effectiveness of Clinical Decision Tools in Predicting Pulmonary Embolism

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 Clinical Utility of Four Clinical Decision Rules In the Diagnostic Management of Acute Pulmonary Embolism – the Prometheus Diagnosis Study

Blood ◽

10.1182/blood.v116.21.3186.3186 ◽

2010 ◽

Vol 116 (21) ◽

pp. 3186-3186

Author(s):

Inge CM Mos ◽

Renée A Douma ◽

Petra MG Erkens ◽

Tessa AC Nizet ◽

Marc F Durian ◽

...

Keyword(s):

Pulmonary Embolism ◽

Clinical Utility ◽

Acute Pulmonary Embolism ◽

Decision Rules ◽

Clinical Decision ◽

Clinical Decision Rules ◽

Wells Rule ◽

Revised Geneva Score ◽

Acute Pe ◽

D Dimer

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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Impact of a Clinical Decision Rule and a D-dimer plus Alveolar Deadspace Measurement to Rule Out Pulmonary Embolism in an Urban Emergency Department

Academic Emergency Medicine ◽

10.1197/aemj.10.5.502-a ◽

2003 ◽

Vol 10 (5) ◽

pp. 502-a-502 ◽

Cited By ~ 3

Author(s):

J. A Kline

Keyword(s):

Emergency Department ◽

Pulmonary Embolism ◽

Decision Rule ◽

Clinical Decision ◽

Clinical Decision Rule ◽

D Dimer ◽

Urban Emergency Department ◽

Rule Out

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Clinical usefulness of adjusted D-dimer cut-off values to exclude pulmonary embolism in a community hospital emergency department patient population

Acta Radiologica ◽

10.1258/ar.2012.120105 ◽

2012 ◽

Vol 53 (7) ◽

pp. 765-768 ◽

Cited By ~ 10

Author(s):

Josephina A Vossen ◽

Joshua Albrektson ◽

Anirban Sensarma ◽

Scott C Williams

Keyword(s):

Emergency Department ◽

Pulmonary Embolism ◽

Patient Population ◽

Community Hospital ◽

Emergency Department Patient ◽

Clinical Usefulness ◽

Hospital Emergency Department ◽

Hospital Emergency ◽

D Dimer

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Derivation of a Clinical Decision Rule to Decrease the Rate of False-positive D-dimer Assays in Emergency Department Patients Evaluated for Pulmonary Embolism

Academic Emergency Medicine ◽

10.1197/j.aem.2005.03.111 ◽

2005 ◽

Vol 12 (Supplement 1) ◽

pp. 42-42

Author(s):

M. S. Runyon

Keyword(s):

Emergency Department ◽

Pulmonary Embolism ◽

Decision Rule ◽

False Positive ◽

Clinical Decision ◽

Clinical Decision Rule ◽

Emergency Department Patients ◽

D Dimer

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The combination of four different clinical decision rules and an age-adjusted D-dimer cut-off increases the number of patients in whom acute pulmonary embolism can safely be excluded

Thrombosis and Haemostasis ◽

10.1160/th11-08-0587 ◽

2012 ◽

Vol 107 (01) ◽

pp. 167-171 ◽

Cited By ~ 23

Author(s):

Inge Mos ◽

Renée Douma ◽

Petra Erkens ◽

Marc Durian ◽

Tessa Nizet ◽

...

Keyword(s):

Pulmonary Embolism ◽

Decision Rules ◽

Clinical Decision ◽

Clinical Decision Rules ◽

Clinical Probability ◽

Number Of Patients ◽

Wells Score ◽

Revised Geneva Score ◽

D Dimer

SummaryFour clinical decision rules (CDRs) (Wells score, Revised Geneva Score (RGS), simplified Wells score and simplified RGS) safely exclude pulmonary embolism (PE), when combined with a normal D-dimer test. Recently, an age-adjusted cut-off of the D-dimer (patient’s age x 10 μg/l) safely increased the number of patients above 50 years in whom PE could safely be excluded. We validated the age-adjusted D-dimer test and assessed its performance in combination with the four CDRs in patients with suspected PE. A total of 414 consecutive patients with suspected PE who were older than 50 years were included. The proportion of patients in whom PE could be excluded with an ‘unlikely’ clinical probability combined with a normal age-adjusted D-dimer test was calculated and compared with the proportion using the conventional D-dimer cut-off. We assessed venous thromboembolism (VTE) failure rates during three months follow-up. In patients above 50 years, a normal age-adjusted D-dimer level in combination with an ‘unlikely’ CDR substantially increased the number of patients in whom PE could be safely excluded: from 13–14% to 19–22% in all CDRs similarly. In patients over 70 years, the number of exclusions was nearly four-fold higher, and the original Wells score excluded most patients, with an increase from 6% to 21% combined with the conventional and age-adjusted D-dimer cut-off, respectively. The number of VTE failures was also comparable in all CDRs. In conclusion, irrespective of which CDR is used, the age-adjusted D-dimer substantially increases the number of patients above 50 years in whom PE can be safely excluded.

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A Rational Evaluation of the Syncope Patient: Optimizing the Emergency Department Visit

Medicina ◽

10.3390/medicina57060514 ◽

2021 ◽

Vol 57 (6) ◽

pp. 514

Author(s):

Tarek Hatoum ◽

Robert S. Sheldon

Keyword(s):

Emergency Department ◽

Diagnostic Yield ◽

Clinical Decision ◽

Emergency Department Visits ◽

Decision Tools ◽

Short And Long Term ◽

Electrocardiogram Ecg ◽

Structured Approach

Syncope accounts for up to 2% of emergency department visits and results in the hospitalization of 12–86% of patients. There is often a low diagnostic yield, with up to 50% of hospitalized patients being discharged with no clear diagnosis. We will outline a structured approach to the syncope patient in the emergency department, highlighting the evidence supporting the role of clinical judgement and the initial electrocardiogram (ECG) in making the preliminary diagnosis and in safely identifying the patients at low risk of short- and long-term adverse events or admitting the patient if likely to benefit from urgent intervention. Clinical decision tools and additional testing may aid in further stratifying patients and may guide disposition. While hospital admission does not seem to offer additional mortality benefit, the efficient utilization of outpatient testing may provide similar diagnostic yield, preventing unnecessary hospitalizations.

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