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Purpose To assess the percentage of computed tomography pulmonary angiography (CTPA) procedures that could have been avoided by methodical application of the Revised Geneva Score (RGS) coupled with age-adjusted D-dimer cut-offs rather than only clinical judgment in Emergency Department patients with suspected pulmonary embolism (PE). Material and methods Between November 2019 and May 2020, 437 patients with suspected PE based on symptoms and D-dimer test were included in this study. All patients underwent to CTPA. For each patient, we retrospectively calculated the age-adjusted D-dimer cut-offs and the RGS in the original version. Finally, CT images were retrospectively reviewed, and the presence of PE was recorded. Results In total, 43 (9.84%) CTPA could have been avoided by use of RGS coupled with age-adjusted D-dimer cut-offs. Prevalence of PE was 14.87%. From the analysis of 43 inappropriate CTPA, 24 (55.81%) of patients did not show any thoracic signs, two (4.65%) of patients had PE, and the remaining patients had alternative thoracic findings. Conclusion The study showed good prevalence of PE diagnoses in our department using only physician assessment, although 9.84% CTPA could have been avoided by methodical application of RGS coupled with age-adjusted D-dimer cut-offs.

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 &lt, 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 &gt, 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.

Objective Multiple professional societies recommend pre‐test probability (PTP) assessment prior to imaging in the evaluation of patients with suspected pulmonary embolism (PE), however, PTP testing remains uncommon, with imaging occurring frequently and rates of confirmed PE remaining low. The goal of this study was to assess the impact of a clinical decision support tool embedded into the electronic health record to improve the diagnostic yield of computerized tomography pulmonary angiography (CTPA) in suspected patients with PE in the emergency department (ED). Methods Between July 24, 2014 and December 31, 2016, 4 hospitals from a healthcare system embedded an optional electronic clinical decision support system to assist in the diagnosis of pulmonary embolism (ePE). This system employs the Pulmonary Embolism Rule‐out Criteria (PERC) and revised Geneva Score (RGS) in series prior to CT imaging. We compared the diagnostic yield of CTPA) among patients for whom the physician opted to use ePE versus the diagnostic yield of CTPA when ePE was not used. Results During the 2.5‐year study period, 37,288 adult patients were eligible and included for study evaluation. Of eligible patients, 1949 of 37,288 (5.2%) were enrolled by activation of the tool. A total of 16,526 CTPAs were performed system‐wide. When ePE was not engaged, CTPA was positive for PE in 1556 of 15,546 scans for a positive yield of 10.0%. When ePE was used, CTPA identified PE in 211 of 980 scans (21.5% yield) (P

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2021. For permissions please email: Journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model), Pulmonary embolism (PE) is a recognized complication of SARS-COV2 infection due to hypercoagulability. Before the COVID era, the need for computed tomography pulmonary angiography (CTPA) to rule out PE was determined by clinical probability, based on Wells and Geneva scores, in association with D-dimer measurements. However, patients with SARS-COV2 infection have a pro-thrombotic and pro-inflammatory state which may compromise the usefulness of these algorithms to select patients for CTPA.

Funding Acknowledgements Type of funding sources: None. Background During the COVID-19 pandemic many countries have imposed lockdown restrictions to movement. Since the 18th of March in Portugal, thousands of people have been confined to their homes. While hospital admissions for COVID-19 patients increased exponentially, admissions for non-COVID-19 patients decreased dramatically. However, it remains unclear whether lockdown-related immobility can contribute to the increased incidence of pulmonary embolism. Purpose To compare the incidence of pulmonary embolism (PE) during the lockdown period (Abril 1 to May 31, 2020) compared to the reference period in 2019. Methods Retrospective study of consecutive outpatients who presented to the emergency department and underwent computed tomography pulmonary angiography (CTPA) due to suspicion of PE. Results Compared to the same period of 2019, the lockdown period was associated with a significant increase in PE diagnosis (29 versus 18 patients). PE patients during lockdown were older (median age 71 years; interquartile range [IQR][60-85] versus 59 years [44-76]; p = 0.046) and have lower prevalence of active cancer (14% versus 33% in the reference period). Women represent 55% (n = 16) of patients in lockdown group (versus 50% in 2019 group). Clinical probability (GENEVA score) was similar in both groups (median score 2.72 in lockdown group and 2.50 in reference group, p = 0.452). None of the patients with PE was diagnosed with COVID-19. Conclusion We have observed a marked increase (62%) in PE diagnosis during lockdown period compared to the reference period, which can be explained by the reduction in physical activity due to teleworking and closure of gyms and sports activities. These data reinforce the importance of promoting physical activity programs at home. The role of pharmacological or mechanical thromboprophylaxis in this scenario remains unclear.

Introduction: The diagnosis of pulmonary embolism (PE) is challenging to make and is often missed in the emergency centre. The diagnostic work-up of PE has been improved by the use of clinical decision rules (CDRs) and CT pulmonary angiography (CTPA) in high-income countries. CDRs have not been validated in the South African environment where HIV and tuberculosis (TB) are highly prevalent. Both conditions are known to induce a hyper-coagulable state. The objective of this study was to describe the clinical presentation and diagnostic workup of suspected PE in our setting and to determine the prevalence of HIV and TB in our sample of patients with confirmed PE. Methods: This study was a retrospective chart review of patients with suspected PE who had CTPAs performed between October 2013 and October 2015 at a district hospital in Cape Town, South Africa. Data were collected on demographics, presenting signs and symptoms, vitals, bedside investigations, HIV and TB status. A Revised Geneva score (RGS) was calculated retrospectively and compared to the CTPA result. Results: The median age of patients with confirmed PE was 45 years and 68% were female. The CTPA yield for PE in our study population was 32%. The most common presenting complaint was dyspnoea (83%). Deep venous thrombosis (DVT) was present in 29%. No sign or symptom was observed to be markedly different in patients with confirmed PE vs no PE. Among patients with confirmed PE, 37% were HIV positive and 52% had current TB. RGS compared poorly with CTPA results. Conclusions: PE remains a diagnostic challenge. In our study, the retrospectively calculated CDR was not predictive of PE in a population with a high prevalence of HIV and TB. Emergency physicians should be cautious when making a clinical probability assessment of PE in this setting. However, further studies are needed to develop a predictive CDR for the local environment. Keywords: TB., Pulmonary embolism, HIV, Diagnosis of pulmonary embolism

Anna Lipinska, Anna Ledakowicz-Polak, Grzegorz Krauza, Katarzyna Przybylak, Marzenna Zielinska Intensive Cardiac Therapy Clinic, Department of Interventional Cardiology and Electrocardiology, Central Clinical Hospital, Lodz, Poland Background: Wells and Geneva scores are widely used in the assessment of pretest probability of pulmonary embolism (PE). Objective: The objective of this study was to examine the hypothesis that mean platelet volume (MPV) may better predict PE than the clinical prediction rules. Methods: A study was performed among patients with PE. Baseline characteristics and complete blood counts including MPV were prospectively recorded upon admission. To assess clinical probability in patients with PE risk, we used Wells and Geneva scores. Results: Data records of 136 patients (males: 44%) with median age of 66 years (interquartile range [IQR] 57.5–78.0) diagnosed with PE at the Intensive Cardiac Therapy Clinic in Lodz (Poland) were analyzed. Baseline characteristics indicate that patients suffered from arterial hypertension (65%), obesity (32%), and diabetes mellitus (24%). Furthermore, they reported active smoking (21%), prolonged immobilization (20%), major surgery (21%), pregnancy (4%), and oral contraceptives (9%). Patients presented with various symptoms. The MPV, plateletcrit, and D-dimer values on admission were respectively as follows: 10.71 (IQR 3.29–13.67), 0.2 (IQR 0.15–0.24), and 9.23 (IQR 8.5–9.85). The study revealed that Wells score correlated significantly with an elevated MPV value (P0.05). According to our results, there is a lack of coherence between Wells and Geneva scores (P>0.05). Finally, we determined that the optimum MPV level cutoff point for PE on admission with reference to the original Wells score is 9.6 fL. Conclusion: MPV may be considered useful as an adjunctive or independent predictive marker for PE used in lieu of clinical prediction rules. Keywords: pulmonary embolism, mean platelet volume, Wells score, Geneva score

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.

Background: The diagnosis of pulmonary embolism (PE) in pregnant women represents an ongoing challenge. As in the general population, the first step in pregnant women with suspected PE consists of assessing clinical pre-test probability (PTP). However, no dedicated clinical decision rule has been developed in this population. Objective: To propose a new version of the Geneva score adapted to pregnant women with suspected PE. Methods: Data from a multicenter, prospective management outcome study including 395 women with suspected PE, in whom PTP was assessed using the Geneva score, were used. We first removed items which were present in none of the patients (cancer, age >65 years). Receiver operating characteristic (ROC) curve analysis was then performed for quantitative variables and the optimal threshold defined. The obtained Pregnancy-Adapted Geneva Score (PAG Score) comprised seven items, including an age 40 years or older and a heart rate >110 beats per minute. Results: The PAG Score showed a high discriminative power to identify patients with a low, intermediate, or high PTP, associated with increasing prevalence of PE, 2.3%, 11.6%, and 61.5%, respectively. The ROC curves showed an area under the curve of 0.795 for the PAG Score compared to 0.684 for the Geneva score. Conclusion: In pregnant women with suspected PE, the PAG Score shows a high discriminative power to identify patients at low, intermediate, or high PTP. It has the strength of being a fully objective decision rule, is clinically relevant, easy to compute, and should now be tested in a prospective outcome study.

Background The clinical symptoms and signs of chronic obstructive pulmonary disease (COPD) exacerbation and pulmonary embolism (PE) may overlap; D-dimer is proven to be higher in patients suffering from COPD exacerbation. Objective To obtain a new cut-off value of D-dimer in subjects with exacerbation of COPD for prospecting those with PE and to avoid unnecessary imaging or contrast-enhanced investigations. Methods The study included 83 male subjects with acute exacerbation of COPD and 30 healthy control subjects. Data on serum D-dimer levels, calculated age-adjusted D-dimer levels, and revised Geneva score were obtained for all participants. COPD subjects were divided into three subgroups according to the revised Geneva score values; those with high D-dimer levels underwent chest computed tomography with pulmonary angiography (CTPA). Results Comparisons among the three subgroups revealed significant differences regarding exacerbations, hospitalisations per year, revised Geneva score results, D-dimer values, and positive CTPA results. While there were no significant differences between the three subgroups and the control group with respect to age, smoking, and BMI, the D-dimer values showed significant differences. Receiver operating characteristic (ROC) curve was analysed to calculate the cut-off value of the serum D-dimer level. Conclusion Given that D-dimer levels are high in subjects having COPD exacerbation, determining a new cut-off value is mandatory to rule out PE and avoid unnecessary further investigations.

BackgroundPulmonary embolism (PE) is a leading cause of death in pregnancy and post partum, but the symptoms of PE are common in normal pregnancy. Simple diagnostic tests are needed to select women for diagnostic imaging.ObjectiveTo estimate the accuracy, effectiveness and cost-effectiveness of clinical features, decision rules and biomarkers for selecting pregnant or postpartum women with a suspected PE for imaging.DesignAn expert consensus study to develop new clinical decision rules, a case–control study of women with a diagnosed PE or a suspected PE, a biomarker study of women with a suspected PE or diagnosed deep-vein thrombosis (DVT) and decision-analysis modelling.SettingEmergency departments and consultant-led maternity units.ParticipantsPregnant/postpartum women with a diagnosed PE from any hospital reporting to the UK Obstetric Surveillance System research platform and pregnant/postpartum women with a suspected PE or diagnosed DVT at 11 prospectively recruiting sites.InterventionsClinical features, decision rules and biomarkers.Main outcome measuresSensitivity, specificity, area under receiver operating characteristic (AUROC) curve, quality-adjusted life-years (QALYs) and health-care costs.ResultsThe primary analysis involved 181 women with PE and 259 women without PE in the case–control study and 18 women with DVT, 18 with PE and 247 women without either in the biomarker study. Most clinical features showed no association with PE. The AUROC curves for the clinical decision rules were as follows: primary consensus, 0.626; sensitive consensus, 0.620; specific consensus, 0.589; PE rule-out criteria, 0.621; simplified Geneva score, 0.579; Wells’s PE criteria (permissive), 0.577; and Wells’s PE criteria (strict), 0.732. The sensitivities and specificities of the D-dimer measurement were 88.4% and 8.8%, respectively, using a standard threshold, and 69.8% and 32.8%, respectively, using a pregnancy-specific threshold. Previous venous thromboembolism, long-haul travel, multiple pregnancy, oxygen saturation, recent surgery, temperature and PE-related chest radiograph abnormality were predictors of PE on multivariable analysis. We were unable to derive a rule through multivariable analysis or recursive partitioning with adequate accuracy. The AUROC curves for the biomarkers were as follows: activated partial thromboplastin time – 0.669, B-type natriuretic peptide – 0.549, C-reactive protein – 0.542, Clauss fibrinogen – 0.589, enzyme-linked immunosorbent assay D-dimer – 0.668, Innovance D-dimer (Siemens Healthcare Diagnostics Products GmbH, distributed by Sysmex UK Ltd, Milton Keynes, UK) – 0.651, mid-regional pro-atrial natriuretic peptide (MRproANP) – 0.524, prothrombin fragment 1 + 2 – 0.562, plasmin-antiplasmin – 0.639, Prothombin time – 0.613, thrombin generation lag time – 0.702, thrombin generation endogenous potential – 0.559, thrombin generation peak – 0.596, thrombin generation time to peak – 0.655, tissue factor – 0.531 and troponin – 0.597. The repeat analysis excluding women who had received anticoagulation was limited by the small number of women with PE (n = 4). The health economic analysis showed that a strategy of scanning all women with a suspected PE accrued more QALYs and incurred fewer costs than any selective strategy based on a clinical decision rule and was therefore the dominant strategy.LimitationsThe findings apply specifically to the diagnostic assessment of women with a suspected PE in secondary care.ConclusionsClinical features, decision rules and biomarkers do not accurately, effectively or cost-effectively select pregnant or postpartum women with a suspected PE for diagnostic imaging.Future workNew diagnostic technologies need to be developed to detect PE in pregnancy.Trial registrationCurrent Controlled Trials ISRCTN21245595.Funding detailsThis project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 22, No. 47. See the NIHR Journals Library website for further project information.

Essentials The simplified Geneva score allows easier pretest probability assessment of pulmonary embolism (PE). We prospectively validated this score in the ADJUST-PE management outcome study. The study shows that it is safe to manage patients with suspected PE according to this score. The simplified Geneva score is now ready for use in routine clinical practice. SummaryBackground Pretest probability assessment by a clinical prediction rule (CPR) is an important step in the management of patients with suspected pulmonary embolism (PE). A limitation to the use of CPRs is that their constitutive variables and corresponding number of points are difficult to memorize. A simplified version of the Geneva score (i.e. attributing one point to each variable) has been proposed but never been prospectively validated. Aims Prospective validation of the simplified Geneva score (SGS) and comparison with the previous version of the Geneva score (GS). Methods In the ADJUST-PE study, which had the primary aim of validating the age-adjusted D-dimer cut-off, the SGS was prospectively used to determine the pretest probability in a subsample of 1621 study patients. Results Overall, PE was confirmed in 294 (18.1%) patients. Using the SGS, 608 (37.5%), 980 (60.5%) and 33 (2%) were classified as having a low, intermediate and high clinical probability. Corresponding prevalences of PE were 9.7%, 22.4% and 45.5%; 490 (30.1%) patients with low or intermediate probability had a D-dimer level below 500 μg L−1 and 653 (41.1%) had a negative D-dimer test according to the age-adjusted cut-off. Using the GS, the figures were 491(30.9%) and 650 (40.9%). None of the patients considered as not having PE based on a low or intermediate SGS and negative D-dimer had a recurrent thromboembolic event during the 3-month follow-up. Conclusions The use of SGS has similar efficiency and safety to the GS in excluding PE in association with the D-dimer test.

Essentials Safety of computed tomography (CTPA) to exclude pulmonary embolism (PE) in all patients is debated. We analysed the outcome of PE-likely outpatients left untreated after negative CTPA alone. The 3-month venous thromboembolic risk in these patients was very low (0.6%; 95% CI 0.2–2.3). Multidetector CTPA alone safely excludes PE in patients with likely clinical probability. SummaryBackground In patients with suspected pulmonary embolism (PE) classified as having a likely or high pretest clinical probability, the need to perform additional testing after a negative multidetector computed tomography pulmonary angiography (CTPA) finding remains a matter of debate. Objectives To assess the safety of excluding PE by CTPA without additional imaging in patients with a likely pretest probability of PE. Patients/Methods We retrospectively analyzed patients included in two multicenter management outcome studies that assessed diagnostic algorithms for PE diagnosis. Results Two thousand five hundred and twenty-two outpatients with suspected PE were available for analysis. Of these 2522 patients, 845 had a likely clinical probability as assessed by use of the simplified revised Geneva score. Of all of these patients, 314 had the diagnosis of PE excluded by a negative CTPA finding alone without additional testing, and were left without anticoagulant treatment and followed up for 3 months. Two patients presented with a venous thromboembolism (VTE) during follow-up. Therefore, the 3-month VTE risk in likely-probability patients after a negative CTPA finding alone was 2/314 (0.6%; 95% confidence interval [CI] 0.2–2.3%). Conclusions In outpatients with suspected PE and a likely clinical probability as assessed by use of the simplified revised Geneva score, CTPA alone seems to be able to safely exclude PE, with a low 3-month VTE rate, which is similar to the VTE rate following the gold standard, i.e. pulmonary angiography.

Background: Patients with suspected pulmonary embolism (PE) should be evaluated for the clinical probability of PE using an applicable risk score. The Geneva prognostic score, the PE Severity Index (PESI), and its simplified version (sPESI) are well-known clinical prognostic scores for PE. The purpose of this study was to analyze these clinical scores as prognostic tools. Materials and Methods: A historical cohort study was conducted on patients with acute PE in Al-Zahra Teaching Hospital, Isfahan, Iran, from June 2013 to August 2014. To compare survival in the 1-month follow-up and factor-analyze mortality from the survival graph, Kaplan–Meier, and log-rank logistic regression were applied. Results: Two hundred and twenty four patients were assigned to two “low risk” and “high risk” groups using the three versions of “Simplified PESI, Original PESI, and Simplified Geneva.” They were followed for a period of 1 month after admission. The overall mortality rate within 1 month from diagnosis was about 24% (95% confidence interval, 21.4–27.2). The mortality rate of low risk PE patients was about 4% in the PESI, 17% in the Geneva, and

A 63-year-old female presented with abnormal lung shadows but had, apart from this, few symptoms. Computed tomography (CT) revealed multiple nodules and blockage of the pulmonary artery. She was immediately diagnosed with pulmonary artery sarcoma based on a careful differential diagnosis and underwent surgery. Her tumor was pathologically diagnosed as leiomyosarcoma (i.e. intimal sarcoma). Pulmonary artery sarcoma can be easily confounded with thromboembolism in a clinical setting and some cases are diagnosed post mortem only. In our case, clinical prediction scores (Wells score, Geneva score, and revised Geneva score) for the pulmonary embolism showed low probability. Moreover, chest CT showed uncommon findings for pulmonary thromboembolism, as the nodules were too big for thrombi. Because surgical resection can provide the only hope of long-term survival in cases of pulmonary artery sarcoma, clinicians should consider this possibility in the differential diagnosis of pulmonary embolism. Clinical prediction scores and CT findings might help to reach the correct diagnosis of pulmonary artery sarcoma.

Amaç: Pulmoner tromboemboli (PTE) tanısı ile acil servisimize başvuran hastaların klinik, radyolojik ve laboratuar bulgularını incelemek ve klinik skorlamaların tanıdaki etkinliğini değerlendirmektir. Gereç ve Yöntemler: Bu çalışmada üniversitemiz acil servisine başvuran 33 pulmoner tromboemboli olgusu geriye dönük olarak incelendi. Bulgular: Olguların yaş ortalaması 56,218,2 yıl idi. Kadın/erkek oranı ise 1,5 idi. Başvuru yakınmaları arasında en sık neden nefes darlığı (%51,5) idi. Risk faktörleri arasında ise çoğunluğu (%39,3) operasyona bağlı immobilizasyon hikayesi oluşturmaktaydı. Well's klinik skorlamasına göre olguların 29'u (%87,8) yüksek olasılıklı iken modifiye geneva skoruna göre ise olguların 18'i (%55,5) yüksek olasılıklı grupta idi. Well's skorunun yüksek olasılıklı PTE tahmin oranı Modifiye Geneva skoruna göre anlamlı oranda fazla idi (p0,017). En sık görülen klinik bulgular taşipne (%69,6) ve taşikardi (%27,3) idi. 15 (%45,4) olguda patolojik akci- ğer grafisi vardı. Bilgisayarlı Tomografik (BT) Anjiografide PTE en sık bilateral pulmoner ana dallara yerleşim göstermekte idi. Yirmi yedi (%81,8) olguya standart düşük molekül ağırlıklı heparinwarfarin tedavisi uygulanırken 6 (%18,2) olguya ise doku plazminojen aktivatörü (tPA) tedavisi uygulanmıştı. Sonuç: PTE tanısında; klinik, laboratuar ve radyolojik bulguların birlikte değerlendirilmesi önemlidir. PTE kuşkusu olan hastaların klinik olasılık tahmininde Well's skorunun kullanımı tercih edilmelidir., Aim: To examine the clinical, radiological, and laboratory findings of pulmonary thromboembolism (PTE) patients who were admitted to our emergency department and to evaluate the effectiveness of clinical diagnosis scores.Materials and Methods: We retrospectively evaluated 33 PTE patients who were referred to our emergency department. Results: The mean age of the patients was 56.2±18.2 years. The female:male ratio was 1.5. The most common cause of complaints was dyspnoea (51.5%). Risk factors in the majority (39.3%) included immobilisation due to surgery. According to the Wells clinical scoring system, 29 patients (87.8%) had a high probability of PTE; however, 18 of the patients (55.5%) had high probability of PTE according to the modified Geneva score. The estimated rate ratio of high probability of PTE with the Wells score was statistically significant compared with the estimate rate ration with the modified Geneva score (p0.017). The most common clinical findings included tachypnoea (69.6%) and tachycardia (27.3%). Fifteen (45.4%) patients had pathologic chest X-ray findings. Computed tomographic (CT) angiography most often showed PTE placement of the bilateral pulmonary main branches. While standard low-molecular-weight heparin and warfarin treatment was administered to 27 (81.8%) patients, tissue plasminogen activator (tPA) treatment was administered to 6 (18.2%) patients. Conclusion: The evaluation of clinical, laboratory and radiological findings together in PTE diagnosis is important. It is preferable to use the Wells score for the estimation of clinical probability in patients with suspected PTE

To the Editor: Establishing a prompt diagnosis of acute pulmonary embolism is a diagnostic challenge, as the clinical presentation ranges from haemodynamic shock to very subtle symptoms mimicking those of other cardiovascular or pulmonary diseases [1]. This diverse presentation facilitates diagnostic delay and, consequently, also a delay in treatment initiation, which might be an important prognostic indicator for patients with acute pulmonary embolism [1]. The standard diagnostic algorithm for suspected acute pulmonary embolism consists of sequential pre-test probability determination, D-dimer testing and computed tomography pulmonary angiography (CTPA) [2]. The pre-test probability can be estimated using a validated clinical decision rule (CDR), such as the Wells score and the revised Geneva score (RGS) [3, 4]. In addition to an excellent sensitivity and specificity, the main advantage of this diagnostic algorithm is that 20–30% of all patients with a clinical suspicion can be managed without CTPA, since an unlikely clinical probability in combination with a normal high-sensitive D-dimer test result has been shown to accurately rule out acute symptomatic pulmonary embolism [5]. The significance of the appropriate use of this diagnostic management strategy in patients with suspected pulmonary embolism has been highlighted by a prospective cohort study [6]. In patients with inappropriate diagnostic management, the diagnostic failure rate was 7.7%, compared to 1.2% for those patients in whom pulmonary embolism was ruled out according to the strategy (p

International audience; BACKGROUND: The Pulmonary Embolism Rule-out Criteria (PERC) rule is a clinical diagnostic rule designed to exclude pulmonary embolism (PE) without further testing. We sought to externally validate the diagnostic performance of the PERC rule alone and combined with clinical probability assessment based on the revised Geneva score. METHODS: The PERC rule was applied retrospectively to consecutive patients who presented with a clinical suspicion of PE to six emergency departments, and who were enrolled in a randomized trial of PE diagnosis. Patients who met all eight PERC criteria [PERC((-))] were considered to be at a very low risk for PE. We calculated the prevalence of PE among PERC((-)) patients according to their clinical pretest probability of PE. We estimated the negative likelihood ratio of the PERC rule to predict PE. RESULTS: Among 1675 patients, the prevalence of PE was 21.3%. Overall, 13.2% of patients were PERC((-)). The prevalence of PE was 5.4% [95% confidence interval (CI): 3.1-9.3%] among PERC((-)) patients overall and 6.4% (95% CI: 3.7-10.8%) among those PERC((-)) patients with a low clinical pretest probability of PE. The PERC rule had a negative likelihood ratio of 0.70 (95% CI: 0.67-0.73) for predicting PE overall, and 0.63 (95% CI: 0.38-1.06) in low-risk patients. CONCLUSIONS: Our results suggest that the PERC rule alone or even when combined with the revised Geneva score cannot safely identify very low risk patients in whom PE can be ruled out without additional testing, at least in populations with a relatively high prevalence of PE.

International audience; SUMMARY BACKGROUND: Pretest probability assessment is necessary to identify patients in whom pulmonary embolism (PE) can be safely ruled out by a negative D-dimer without further investigations. OBJECTIVE: Review and compare the performance of available clinical prediction rules (CPRs) for PE probability assessment. PATIENTS/METHODS: We identified studies that evaluated a CPR in patients with suspected PE from Embase, Medline and the Cochrane database. We determined the 95% confidence intervals (CIs) of prevalence of PE in the various clinical probability categories of each CPR. Statistical heterogeneity was tested. RESULTS: We identified 9 CPR and included 29 studies representing 31215 patients. Pooled prevalence of PE for three-level scores (low, intermediate or high clinical probability) was: low, 6% (95% CI, 4-8), intermediate, 23% (95% CI, 18-28) and high, 49% (95% CI, 43-56) for the Wells score; low, 13% (95% CI, 8-19), intermediate, 35% (95% CI, 31-38) and high, 71% (95% CI, 50-89) for the Geneva score; low, 9% (95% CI, 8-11), intermediate, 26% (95% CI, 24-28) and high, 76% (95% CI, 69-82) for the revised Geneva score. Pooled prevalence for two-level scores (PE likely or PE unlikely) was 8% (95% CI,6-11) and 34% (95% CI,29-40) for the Wells score, and 6% (95% CI, 3-9) and 23% (95% CI, 11-36) for the Charlotte rule. CONCLUSION: Available CPR for assessing clinical probability of PE show similar accuracy. Existing scores are, however, not equivalent and the choice among various prediction rules and classification schemes (three- versus two-level) must be guided by local prevalence of PE, type of patients considered (outpatients or inpatients) and type of D-dimer assay applied.

International audience; BACKGROUND: The risk of recurrence of pulmonary embolism (PE) is higher in men than in women. Differences in clinical presentation of deep vein thrombosis (DVT) have been reported between the two genders but comparative data on PE are lacking. OBJECTIVES: To compare clinical characteristics between women and men with suspected and confirmed PE and their impact on clinical probability prediction scores and on diagnostic work-up of PE, and to assess whether differences at presentation could account for the increased recurrence rate in men. METHODS: Combined data from three prospective cohort studies including a total of 3414 outpatients with suspected PE were analyzed retrospectively. Clinical characteristics, pretest probability of PE, diagnostic yield of non-invasive tests and VTE recurrence rate were compared between genders. RESULTS: The overall prevalence of PE was similar among women and men (22.3% vs. 23.1%; P = 0.55). The clinical probability prediction scores (Geneva score and Wells score) performed equally well in both genders. A non-invasive diagnostic work-up was possible more often in men than in women. The proportion of PE-associated proximal DVT was higher in men than in women (43% vs. 33%; P = 0.009). VTE recurrence rate was also higher in men than women with PE (5.0% vs. 2.3%; P = 0.045). CONCLUSION: In spite of some differences in the clinical presentation of PE between women and men, clinical probability prediction scores perform equally in both genders. A higher prevalence of PE-associated proximal DVT in men could possibly indicate greater severity of PE episodes and partly account for the higher VTE recurrence rate in men.

SummaryClinical outcome studies have shown that it is safe to withhold anticoagulant therapy in patients with suspected pulmonary embolism (PE) who have a negative D-dimer result and a low pre-test probability (PTP) either using a PTP model or clinical gestalt. It was the objective of the present study to assess the safety of the combination of a negative VIDAS© D-dimer result in combination with a non-high PTP using the Wells or Geneva models to exclude PE. A systematic literature search strategy was conducted using MEDLINE, EMBASE, the Cochrane Register of Controlled Trials and all EBM Reviews. Seven studies (6 prospective management studies and 1 randomised controlled trial) reporting failure rates at three months were included in the analysis. Non-high PTP was defined as “unlikely” using the Wells’ model, or “low/intermediate” PTP using either the Geneva score, the Revised Geneva Score, or clinical gestalt. Two reviewers independently extracted data onto standardised forms. A total of 5,622 patients with low/intermediate or unlikely PTP were assessed using the VIDAS D-dimer. PE was ruled out by a negative D-dimer test in 2,248 (40%, 95% confidence intervals [CI] 38.7 to 41.3%) of them. The three-month thromboembolic risk in patients left untreated on the basis of a low/intermediate or unlikely PTP and a negative D-dimer test was 3/2,166 (0.14%, 95% CI 0.05 to 0.41%). In conclusion, the combination of a negative VIDAS D-dimer result and a non-high PTP effectively and safely excludes PE in an important proportion of outpatients with suspected PE.

▴ Le Gal G, Righini M, Roy PM, et al. Prediction of pulmonary embolism in the emergency department: the revised Geneva score. Ann Intern Med2006;144:165–71 [OpenUrl][1][CrossRef][2][PubMed][3][Web of Science][4] Clinical variables were derived and validated in two independent cohorts of patients suspected of having a pulmonary embolism (PE). There were 965 patients in the derivation group and 756 in the validation group. Univariate analysis identified 10 variables statistically associated with PE, … [1]: {openurl}?query=rft.jtitle%253DAnnals%2Bof%2BInternal%2BMedicine%26rft.stitle%253DANN%2BINTERN%2BMED%26rft.issn%253D0003-4819%26rft.aulast%253DLe%2BGal%26rft.auinit1%253DG.%26rft.volume%253D144%26rft.issue%253D3%26rft.spage%253D165%26rft.epage%253D171%26rft.atitle%253DPrediction%2Bof%2BPulmonary%2BEmbolism%2Bin%2Bthe%2BEmergency%2BDepartment%253A%2BThe%2BRevised%2BGeneva%2BScore%26rft_id%253Dinfo%253Adoi%252F10.7326%252F0003-4819-144-3-200602070-00004%26rft_id%253Dinfo%253Apmid%252F16461960%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/external-ref?access_num=10.7326/0003-4819-144-3-200602070-00004&link_type=DOI [3]: /lookup/external-ref?access_num=16461960&link_type=MED&atom=%2Fthoraxjnl%2F61%2F8%2F662.atom [4]: /lookup/external-ref?access_num=000235074800002&link_type=ISI

CONTEXT: Previous studies have evaluated the safety of relatively complex combinations of clinical decision rules and diagnostic tests in patients with suspected pulmonary embolism. OBJECTIVE: To assess the clinical effectiveness of a simplified algorithm using a dichotomized clinical decision rule, D-dimer testing, and computed tomography (CT) in patients with suspected pulmonary embolism. DESIGN, SETTING, AND PATIENTS: Prospective cohort study of consecutive patients with clinically suspected acute pulmonary embolism, conducted in 12 centers in the Netherlands from November 2002 through December 2004. The study population of 3306 patients included 82% outpatients and 57% women. INTERVENTIONS: Patients were categorized as "pulmonary embolism unlikely" or "pulmonary embolism likely" using a dichotomized version of the Wells clinical decision rule. Patients classified as unlikely had D-dimer testing, and pulmonary embolism was considered excluded if the D-dimer test result was normal. All other patients underwent CT, and pulmonary embolism was considered present or excluded based on the results. Anticoagulants were withheld from patients classified as excluded, and all patients were followed up for 3 months. MAIN OUTCOME MEASURE: Symptomatic or fatal venous thromboembolism (VTE) during 3-month follow-up. RESULTS: Pulmonary embolism was classified as unlikely in 2206 patients (66.7%). The combination of pulmonary embolism unlikely and a normal D-dimer test result occurred in 1057 patients (32.0%), of whom 1028 were not treated with anticoagulants; subsequent nonfatal VTE occurred in 5 patients (0.5% [95% confidence interval {CI}, 0.2%-1.1%]). Computed tomography showed pulmonary embolism in 674 patients (20.4%). Computed tomography excluded pulmonary embolism in 1505 patients, of whom 1436 patients were not treated with anticoagulants; in these patients the 3-month incidence of VTE was 1.3% (95% CI, 0.7%-2.0%). Pulmonary embolism was considered a possible cause of death in 7 patients after a negative CT scan (0.5% [95% CI, 0.2%-1.0%]). The algorithm was completed and allowed a management decision in 97.9% of patients. CONCLUSIONS: A diagnostic management strategy using a simple clinical decision rule, D-dimer testing, and CT is effective in the evaluation and management of patients with clinically suspected pulmonary embolism. Its use is associated with low risk for subsequent fatal and nonfatal VTE

International audience; BACKGROUND: Single-detector-row computed tomography (CT) has a low sensitivity for pulmonary embolism and must be combined with venous-compression ultrasonography of the lower limbs. We evaluated whether the use of D-dimer measurement and multidetector-row CT, without lower-limb ultrasonography, might safely rule out pulmonary embolism. METHODS: We included 756 consecutive patients with clinically suspected pulmonary embolism from the emergency departments of three teaching hospitals and managed their cases according to a standardized sequential diagnostic strategy. All patients were followed for three months. RESULTS: Pulmonary embolism was detected in 194 of the 756 patients (26 percent). Among the 82 patients with a high clinical probability of pulmonary embolism, multidetector-row CT showed pulmonary embolism in 78, and 1 patient had proximal deep venous thrombosis and a CT scan that was negative for pulmonary embolism. Of the 674 patients without a high probability of pulmonary embolism, 232 (34 percent) had a negative D-dimer assay and an uneventful follow-up; CT showed pulmonary embolism in 109 patients. CT and ultrasonography were negative in 318 patients, of whom 3 had a definite thromboembolic event and 2 died of possible pulmonary embolism during follow-up (three-month risk of thromboembolism, 1.7 percent; 95 percent confidence interval, 0.7 to 3.9). Two patients had proximal deep venous thrombosis and a negative CT scan (risk, 0.6 percent; 95 percent confidence interval, 0.2 to 2.2). The overall three-month risk of thromboembolism in patients without pulmonary embolism would have been 1.5 percent (95 percent confidence interval, 0.8 to 3.0) if the D-dimer assay and multidetector-row CT had been the only tests used to rule out pulmonary embolism and ultrasonography had not been performed. CONCLUSIONS: Our data indicate the potential clinical use of a diagnostic strategy for ruling out pulmonary embolism on the basis of D-dimer testing and multidetector-row CT without lower-limb ultrasonography. A larger outcome study is needed before this approach can be adopted.

Pulmonary embolism is one of the greatest diagnostic challenges in emergency medicine and clinical probability assessment is a fundamental step in its diagnosis. Aim To evaluate the role of estimating clinical probability of pulmonary embolism and to compare between different pre-test probability scoring systems as regards their sensitivity and specificity. Patients and methods We used seven scoring systems (original Geneva score, revised Geneva score, simplified Geneva score, Wells score, simplified Wells score, simplified Charlotte rule, Pisa model) to assess the clinical probability of PE in 41 patients with suspected pulmonary embolism for whom the final diagnosis was based on multislice CT pulmonary angiography (CTPA). Results Twenty-four patients (58.5%) had pulmonary embolism. The scores with the strongest correlation with the result of CTPA were the Pisa model ( P ⩽ 0.001) followed by the original Geneva score and the Wells score ( P ⩽ 0.01). Simplified Wells score had the highest sensitivity (0.92), Pisa model had the highest specificity (0.82) and the highest overall accuracy (0.76). Conclusion For most patients, clinical probability assessment is an easy and effective way to decide which patient should undergo further investigations. Among the studied seven scores, the Pisa model has the best correlation with the CTPA results and it has a good sensitivity, specificity, positive and negative predictive values and the highest overall accuracy.