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AimTo develop a machine learning model to predict the diagnosis of pulmonary embolism (PE).Methods and resultsWe undertook a derivation and internal validation study to develop a risk prediction model for use in patients being investigated for possible PE. The machine learning technique, generalized logistic regression using elastic net, was chosen following an assessment of seven machine learning techniques and on the basis that it optimized the area under the receiver operator characteristic curve (AUC) and Brier score. Models were developed both with and without the addition of D-dimer. A total of 3347 patients were included in the study of whom, 219 (6.5%) had PE. Four clinical variables (O2 saturation, previous deep venous thrombosis or PE, immobilization or surgery, and alternative diagnosis equal or more likely than PE) plus D-dimer contributed to the machine learning models. The addition of D-dimer improved the AUC by 0.16 (95% confidence interval 0.13–0.19), from 0.73 to 0.89 (0.87–0.91) and decreased the Brier score by 14% (10–18%). More could be ruled out with a higher positive likelihood ratio than by the Wells score combined with D-dimer, revised Geneva score combined with D-dimer, or the Pulmonary Embolism Rule-out Criteria score. Machine learning with D-dimer maintained a low-false-negative rate at a true-negative rate of nearly 53%, which was better performance than any of the other alternatives.ConclusionA machine learning model outperformed traditional risk scores for the risk stratification of PE in the emergency department. However, external validation is needed.

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.

Introduction Bolus tracking is applied in computed tomography pulmonary angiography. The time that it takes for contrast to reach a predefined threshold in the pulmonary artery is called time to threshold (TTT). Our purpose was to analyse possible associations between TTT and circulatory state and prognosis in patients with acute pulmonary embolism (PE). Methods In a single-centre, retrospective study 138 patients with PE and contrast administration via peripheral venous line were included. Clinical parameters of circulatory state were arterial pH, systolic blood pressure, heart rate, sPESI score, Wells score and GENEVA score. Survival was defined as surviving the following 30 days after the PE diagnosis. Results Time to threshold was only weakly correlated with Fi02 (r = 0.26, P = 0.04), pH (r = -0.22, P = 0.009), venous base excess (r = -0.18, P = 0.04) and venous lactate (r = 0.21, P = 0.01). TTT did not correlate with clinical parameters/scores and mortality. There were weak associations between TTT and blood gas analysis parameters. There were no associations with clinically relevant prognosis scores and overall survival. Conclusion Therefore, albeit TTT is an easily assessable parameter of CTPA, the potential use in clinical routine is limited for prognosis stratification in patients with PE.

The relation between long-haul flights (LHF) and venous thromboembolic disease is well established. Nonetheless, the incidence of pulmonary embolisms after these flights is probably underestimated because of the difficulties in case ascertainment. Reunion Island appears to present the ideal geographic conditions for accurately assessing this incidence. We aimed to assess the incidence of pulmonary embolisms in people who had recently taken a LHF to Reunion Island. We conducted a retrospective multi-center descriptive study and included all cases of pulmonary embolisms diagnosed between January 1, 2015, and January 30, 2017 (according to the hospitals' discharge summary database) in the island's four public hospitals within 30 days after taking an LHF to Reunion. We took different delays of diagnosis to calculate the incidence. We have considered the time to diagnosis at 1 month as significant according to the time applied in the Geneva score for risk factors. The study included 45 patients landing on Reunion over a 2-year period. The total number of passengers arriving by LHF during this period was 1,223,001. The incidence of pulmonary embolism after an LHF was thus calculated at 36.8 per million travelers at 1 month. The incidence for PE diagnosed, after 15 days was 29.4 per million travelers, and after 7 days, it was 21.9 per million travelers. The male/female ratio was 0.67. The mean interval between the flight and symptom onset was 7 days. In our population, the incidence of pulmonary embolisms after LHFs in our study is clearly higher than that reported in the literature (36.8 vs 4.8). Our exhaustive data collection probably explains this difference. A case-control study appears necessary to analyze the risk factors for pulmonary embolism after a LHF.

Aims The use of computed tomography pulmonary angiography (CTPA) in the detection of pulmonary embolism (PE) has considerably increased due developing technology and better availability of imaging. The underuse of pre-test probability scores and overuse of CTPA has been previously reported. We sought to investigate the indications for CTPA at a University Hospital emergency clinic and seek for factors eliciting the potential overuse of CTPA. Methods and results Altogether 1001 patients were retrospectively collected and analysed from the medical records using a structured case report form. PE was diagnosed in 222/1001 (22.2%) of patients. Patients with PE had more often prior PE/deep vein thrombosis, bleeding/thrombotic diathesis and less often asthma, chronic obstructive pulmonary disease, coronary artery disease, or decompensated heart failure. Patients were divided into three groups based on Wells PE risk-stratification score and two groups based on the revised Geneva score. A total of 9/382 (2.4%), 166/527 (31.5%), and 47/92 (52.2%) patients had PE in the CTPA in the low, intermediate, and high pre-test likelihood groups according to Wells score, and 200/955 (20.9%) and 22/46 (47.8%) patients had PE in the CTPA in the low-intermediate and the high pre-test likelihood groups according to the revised Geneva score, respectively. D-dimer was only measured from 568/909 (62.5%) and 597/955 (62.5%) patients who were either in the low or the intermediate-risk group according to Wells score and the revised Geneva score. Noteworthy, 105/1001 (10.5%) and 107/1001 (10.7%) of the CTPAs were inappropriately ordered according to the Wells score and the revised Geneva score. Altogether 168/1001 (16.8%) could theoretically be avoided. Conclusions This study highlights scant utilization of guideline-recommended risk-stratification tools in CTPA use at the emergency department.

Purpose. This study is aimed at assessing the prevalence of pulmonary artery filling defects (PAFDs) consistent with pulmonary artery embolism (PAE) in patients with SARS-CoV-2 infection and at investigating possible radiological or clinical predictors. Materials and Methods. Computed Tomography Pulmonary Angiographies (CTPAs) from 43 consecutive patients with a confirmed COVID-19 infection were retrospectively reviewed, taking into consideration the revised Geneva score and the D-dimer value for each patient. Filling defects within the pulmonary arteries were recorded along with pleural and parenchymal findings such as ground glass opacities, consolidation, crazy paving, linear consolidation, and pleural effusion. All these variables were compared between patients with and without PAFD. The predictive performance of statistically different parameters was investigated using the receiver operating characteristics (ROC). Results. Pulmonary embolism was diagnosed in 15/43 patients (35%), whereas CTPA and parenchymal changes related to pulmonary COVID-19 disease were evident in 39/43 patients (91%). The revised Geneva score and the mean D-dimer value obtained using two consecutive measurements were significantly higher in patients with PAFD. The ROC analysis demonstrated that a mean D-dimer value is the parameter with the higher predictivity (AUC 0.831) that is acut‐off value>1800 μg/lwhich predicts the probability of PAFD with a sensitivity and specificity of 70% and 78%, respectively. Conclusions. This single centre retrospective report shows a high prevalence of pulmonary artery filling defects revealed using CTPA in COVID-19 patients and demonstrates that the mean value of multiple D-dimer measurements may represent a predicting factor of this complication.

The diagnosis of pulmonary embolism is based on several distinct steps. Faced with the suspicion of pulmonary embolism, we are led to use a clinical probability score to guide the rest of the examinations. Revised Geneva score and the Wells score are the two best validated scores. They identify low-, medium-, and high-risk patients in a simple way. The third step, if the clinical probability is not high, is to assay the D-dimers. A negative result excludes pulmonary embolism with a negative predictive value close to 100%. The last step, if they are positive, is the chest angiography-computed tomography (CT) scan that can rule out or confirm pulmonary embolism and to search for severity signs.

Acute pulmonary embolism (PE) is one of the most common causes of cardiovascular death. Most often acute PE is associated with under diagnosis, misdiagnosis and delay in diagnosis and management leading to high morbidity and mortality. PE outcomes will improve with proper evaluation of clinical symptoms and signs, relevant diagnostic tests, identifying high-risk patients suitable for early re-perfusion with I.V. or catheter-directed thrombolytic therapy or surgical embolectomy and in some cases additional use of mechanical circulatory support. During clinical evaluation modified Geneva score, Well’s score, and Simplified pulmonary embolism severity index (sPESI) scores are useful in assessing PE and its adverse outcomes. Hestia criteria are useful in identifying suitable for outpatient management of PE. Long-term management of PE involves identifying patients prone for recurrence and CTPE with appropriate long-term prophylaxis using oral anticoagulants.

Introduction: Venous thromboembolic disease (VTED), associating deep vein thrombosis and pulmonary embolism, represents a major public health issue. The objective of our work is to correlate confirmed VTED with clinical probability scores using elements of interview and clinical examination. Methods: This was a retrospective study from January 1, 2012 to October 27, 2013. Venous thromboembolic disease was diagnosed by lower limb venous Doppler ultrasound for deep vein thrombosis and thoracic CT angiography for pulmonary embolism. Results: Our series included 74 cases of venous thromboembolic disease including 42 cases of deep vein thrombosis and 29 cases of pulmonary embolism. The average age was 48.5 ± 15.9 years. The sex ratio was 0.72. The patients came from the outpatient clinic in 67.57% of cases. The Wells score for pulmonary embolism showed excellent performance in the “Surgery/Cancer” subgroup where the low probability was zero. The revised Geneva score for pulmonary embolism, showing the same proportions of low (14.2%) and intermediate (85.7%) probability, did not discriminate the subgroup of patients with underlying heart disease from the one from a surgical or carcinological environment. Conclusion: Clinical probability scores are more suitable in surgical and oncological settings than in medical settings.

Background Pulmonary embolism (PE) diagnosis can sometimes be challenging due to the disease having nonspecific signs and symptoms at the time of presentation. The present study aimed to evaluate the validity of the D-dimer in combination with the revised Geneva score (RGS) in the prediction of pulmonary embolism. Patients and Methods This is a retrospective study of 2010 patients with suspected PE who had undergone both D-dimer testing followed by chest CT angiography (CTPA), irrespective of the D-dimer test results, at King Abdulaziz Medical City, Riyadh, Saudi Arabia, over 3 years, from Jan. 2016 to Jan. 2019. The predictive accuracy of D-dimer, adjusted D-dimer, and RGS was calculated. The receiver operating characteristic "ROC" curve was applied to allocate the optimum RGS cutoff for PE prediction. Results The overall prevalence of PE was 16%. It was 0%, 25.8%, and 88.9% in low, intermediate, and high clinical probability categories of RGS, respectively. Both conventional and age-adjusted D-dimer thresholds showed significant level of agreement (kappa=0.81, p

According to our experience the 12-lead electrocardiogram (ECG) may be used to estimate the pretest probability of acute pulmonary embolism (acPE). To this end, we devised a novel ECG score (nECGs) composed of 5 known ECG criteria, best characterizing the key pathogenetic steps of acPE. A retrospective derivation cohort including 136 patients with acPE and a prospective validation cohort including 149 consecutive patients were used to devise and validate the nECGs. The latter cohort consisted of 76 patients with acPE and 73 controls presenting with characteristic symptoms of acPE, in whom the work-up ruled out acPE. We compared the diagnostic value of our nECGs with those of another ECG score (Daniel-ECG-score) and of the best prediction rules (3 Wells score and 2 Geneva score variants). The sensitivity (98.7%), negative predictive value (98%), test accuracy (84.4%) and the negative likelihood ratio (LR) (0.019) of the nECGs were superior to those of all other investigated methods. There was no between-groups difference in the positive LR. The specificity (69%) of the nECGs was inferior to those of the Daniel-ECG-score and Wells scores and did not differ or was superior to those of the Geneva score variants. The positive predictive value (77.3%) of the nECGs was superior to those of the 2 Geneva scores and did not differ from those of the other methods. In conclusion, the nECGs due to its superior sensitivity, negative predictive value, test accuracy, and negative LR estimated the pretest probability of acPE better than the Daniel-ECG-score and the prediction rules.

Background/Aim: Pulmonary embolism (PE) is a diagnostic challenge, particularly in prehospital care. The aim of this study was to determine to what extent the evaluation of D-dimer value helps physicians with differentiation of PE and whether D-dimer values are in correlation with the values of revised Geneva score. Methods: Data have been collected for the patients whose D-dimer has been evaluated at the Emergency Care Department of the City of Banja Luka in 2018. Gender, age, symptoms, working diagnosis and D-dimer value have all been recorded and also the fact whether the patient was referred to hospital treatment or not. For each patient the revised Geneva score was determined. Results: Sixty-eight tests were done in 2018. Out of 68 tests, 41 were negative (60.3 %). D-dimer results helped in making decisions about referring patients to the hospital or not (ch2 = 36.32, p < 0.001). Patients with elevated D-dimer levels, especially where the values were four times higher than the reference ones typically were referred to hospital treatment, whereas 67.5% patients with negative D-dimer results were sent home after giving a treatment and advice. In the elderly patients D-dimer was statistically more positive (F = 10.82, p < 0.001). Values of D-dimer were not significantly different regarding gender (ch2 = 2.19, p = 0.33). According to the results of the revised Geneva score, 5.1 % of patients had high risk of PTE, while moderate and low risk had 47.5 % each. Although it has been found that the values of D-dimer were slightly more elevated at higher values of the revised Geneva score and that the difference was not statistically significant (ch2 = 7.71, p = 0.10). Conclusion: Values of D-dimer considerably helped in differentiation of PE in the Emergency Care Department. D-dimer has a high negative predictive value and should be used to exclude PE diagnosis for patients with low clinical probability of PE.

Background Malignancy predisposes patients to higher risk of venous thromboembolism (VTE), which is the second leading cause of death in patients with cancer. Objective This narrative review evaluates VTE in malignancy and the emergency medicine investigation and management of this patient population. Discussion Patients with malignancy are at higher risk of VTE, including deep venous thrombosis (DVT) and pulmonary embolism (PE). Risk factors include the underlying cancer, other hematologic disorders, cancer therapies, and underlying comorbidities. While patients with malignancy and VTE can present similarly to those without malignancy, incidental VTE is more common in cancer patients. Existing scores such as the Wells and Revised Geneva score can assist in risk stratification in patients with malignancy. A negative D-dimer result in the appropriately risk-stratified patient can be used to exclude VTE, though D-dimer is more commonly elevated at baseline in patients with malignancy. Several scoring systems may be useful to predict recurrent risk of VTE, including the Khorana and Ottawa scores. Treatment includes anticoagulation with direct oral anticoagulants (DOACs) or low molecular weight heparin (LMWH). Outpatient therapy may be appropriate in select patients. Conclusions This narrative review provides key updates in the assessment and management of cancer patients with VTE.

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.

Objectives During the COVID-19 pandemic, several studies described an increased chance of developing pulmonary embolism (PE). Several scores have been used to predict the occurrence of PE. In this systematic review, we aim at summarizing the literature on predicting rules for PE in hospitalized COVID-19 patients (HCPs). Methods PUBMED and EMBASE databases were searched to identify articles (1 January 2020-28 April 2021) presenting data pertaining the use of a prediction rule to assess the risk for PE in adult HCPs. The investigated outcome was the diagnosis of PE. Studies presenting data on the use of a single laboratory assay for PE prediction were excluded. Included studies were appraised for methodological quality using the Newcastle - Ottawa Quality Assessment Scale for Cohort Studies (NOS). Results We obtained a refined pool of 12 studies, for a total of 5 scoring systems (Wells score, Geneva score, CHADS2/CHA2DS2VASc/M-CHA2DS2VASc, CHOD score, Padua Prediction Score), and 4526 patients. Only one score was specifically designed for HCPs. Three and nine included studies were prospective and retrospective cohort studies, respectively. Among the examined scores, CHOD score seems promising in terms of predictive ability. Conclusion New prediction rules, specifically developed and validated for estimating the risk of PE in HCP, differentiating ICU from non-ICU patients, and taking into account anticoagulation prophylaxis, comorbidities and the time from COVID-19 diagnosis are needed.

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

INTRODUCTION The recently proposed YEARS algorithm was shown to safely exclude pulmonary embolism (PE) and reduce the use of computed tomography pulmonary angiography (CTPA) among pregnant women with suspected PE. Our aim was to externally validate this finding. METHODS We performed a post hoc analysis of a prospective management outcome study for PE diagnosis in pregnant women. PE was diagnosed with an algorithm that combined the revised Geneva score, D-dimer testing, bilateral lower-limb compression ultrasonography, and CTPA. All women had a 3-month follow-up. All of the items necessary to use the YEARS algorithm were prospectively collected at the time of the study. RESULTS Of the 395 women included in the original study, 371 were available for the present analysis. The PE prevalence was 6.5%. Ninety-one women had no YEARS items, and 280 had one or more items. When the YEARS items were combined with D-dimer levels (

Purpose The aim of this study was to determine rates of and possible reasons for guideline-discordant ordering of CT pulmonary angiography for the evaluation of suspected pulmonary embolism (PE) in the emergency department. Methods A retrospective review was performed of 212 consecutive encounters (January 6, 2016, to February 25, 2016) with 208 unique patients in the emergency department that resulted in CT pulmonary angiography orders. For each encounter, the revised Geneva score and two versions of the Wells criteria were calculated. Each encounter was then classified using a two-tiered risk stratification method (PE unlikely versus PE likely). Finally, the rate of and possible explanations for guideline-discordant ordering were assessed via in-depth chart review. Results The frequency of guideline-discordant studies ranged from 53 (25%) to 79 (37%), depending on the scoring system used; 46 (22%) of which were guideline discordant under all three scoring systems. Of these, 18 (39%) had at least one patient-specific factor associated with increased risk for PE but not included in the risk stratification scores (eg, travel, thrombophilia). Conclusions Many of the guideline-discordant orders were placed for patients who presented with evidence-based risk factors for PE that are not included in the risk stratification scores. Therefore, guideline-discordant ordering may indicate that in the presence of these factors, the assessment of risk made by current scoring systems may not align with clinical suspicion.

The retrospective analysis of 22 patients’ clinical records with the verified pulmonary artery thromboembolism (PE) with various outcomes of a disease is carried out. Hypodiagnostics of PE at a pre-hospital stage is revealed, the predictive importance of Revised Geneva Score scale is shown, predictors of a lethal outcome at a PE are defined: arterial hypotension, tachycardia, McGinn-White syndrome (SI-QIII phenomenon).

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

BACKGROUND We aimed to determine the diagnostic and prognostic value of serum irisin level in patients with acute pulmonary embolism (PE) admitted to the emergency department. METHODS Ninety patients who underwent computed tomography pulmonary angiography (CTPA) due to suspected PE were included in the study. Demographic data, PE risk factors, and associated diseases, vital signs, Wells score, Revised Geneva score, pulmonary embolism severity index (PESI), and simplified PESI (sPESI) were recorded. Irisin levels were measured by enzyme linked-immunosorbent assay. RESULTS Serum irisin level in patients with confirmed PE (n = 45) was significantly lower than that in patients (n = 45) without PE (p = 0.001). On receiver operating characteristic curve analysis, use of optimal irisin cutoff level of 8.6 µg/mL for diagnosis of PE was associated with 82.2% sensitivity, 60% specificity, 67.3% positive predictive value (PPV), and 77.1% negative predictive value (NPV) [area under the curve (AUC): 0.744, 95% confidence in-terval (CI): 0.641 - 0.830, p < 0.001)]. Use of optimal D-dimer cutoff level of 1,720 µg/L was associated with 86.7% sensitivity, 62.2% specificity, 69.6% PPV, and 82.4% NPV (AUC: 0.801, 95% CI: 0.704 - 0.878, p < 0.001). Irisin level showed no significant correlation with Wells score or revised Geneva score; however, irisin level showed a significant negative correlation with PESI and sPESI. CONCLUSIONS Patients with acute PE showed significantly lower serum levels of irisin. The sensitivity, specificity, NPV, and PPV of irisin level for diagnosis of PE were lower than those of D-dimer.

Background and importance Despite its safety and efficacy, venous thromboembolism (VTE) prophylaxis has been proved to be misused in acutely ill medical patients, leading to potential deep vein thrombosis or pulmonary embolism. Aim and objectives Our objectives were to assess the current practices of VTE prevention in acutely ill medical patients in our institution and to explore the underlying reasons for our results. Material and methods This multicentre cross sectional study was conducted among medical patients. Three scores were selected to evaluate the risk of VTE (the PADUA score, the IMPROVE VTE RAM and the Geneva score) and two scores for bleeding risk assessment (the IMPROVE BLEEDING RAM and the ACCP 2012 recommendations). To be considered at high risk, patients had to have at least two positive scores for VTE or bleeding. Our main outcome measure was the prevalence of hospitalised medical patients receiving appropriate thromboprophylaxis (type and dose). The secondary outcome measure was the prevalence of patients receiving an adequate dose among patients receiving LMWH in general, and in special populations. To have a better understanding of our results, a survey of our physicians was performed 1 month later. Results Of the 144 patients included in the study, 52.1% had a high risk of VTE. 70.8% of our patients received appropriate thromboprophylaxis. 18 (9.5%) patients received an unnecessary LMWH and 14 (9.7%) lacked an LMWH. 77% of patients treated with LMWH received an appropriate dose. Only one of two patients with severe renal failure and 24.9% of patients with an extreme body weight received an appropriate dose of LMWH (table 1). 29 physicians answered our subsequent online survey. More than 70% of physicians answered that they had never opened our institutional recommendations and did not follow any specific guidelines when prescribing thromboprophylaxis. Conclusion and relevance VTE prophylaxis in the acutely ill medical patients is not optimal. Improvements must be made, especially regarding communication and healthcare professionals’ education. References and/or acknowledgements Conflict of interest No conflict of interest

Pulmonary embolism (PE) remains a diagnostic challenge in 2021. As the pathology is potentially fatal and signs and symptoms are nonspecific, further investigations are classically required. Based on the Bayesian approach, clinical probability became the keystone of the diagnostic strategy to rule out PE in the case of a negative testing. Several clinical probability assessment methods are validated: gestalt, the Wells score, or the revised Geneva score. While the debate persists as to the best way to assess clinical probability, its assessment allows for the good interpretation of the investigation results and therefore directs the correct diagnostic strategy. The wide availability of computed tomography pulmonary angiography (CTPA) resulted in a major increase in investigations with a moderate increase in diagnosis, without any notable improvement in patient outcomes. This leads to a new challenge for PE diagnosis which is the limitation of the number of testing for suspected PE. We review different strategies recently developed to achieve this goal. The last challenge concerns the implementation in clinical practice. Two approaches are developed: simplification of the strategies versus the use of digital support tools allowing more sophisticated strategies. Artificial intelligence with machine-learning algorithms will probably be a future tool to guide the physician in this complex approach concerning acute PE suspicion.

IMPORTANCE: The prevalence of pulmonary embolism in patients with chronic obstructive pulmonary disease (COPD) and acutely worsening respiratory symptoms remains uncertain. OBJECTIVE: To determine the prevalence of pulmonary embolism in patients with COPD admitted to the hospital for acutely worsening respiratory symptoms. DESIGN, SETTING, AND PARTICIPANTS: Multicenter cross-sectional study with prospective follow-up conducted in 7 French hospitals. A predefined pulmonary embolism diagnostic algorithm based on Geneva score, D-dimer levels, and spiral computed tomographic pulmonary angiography plus leg compression ultrasound was applied within 48 hours of admission; all patients had 3-month follow-up. Patients were recruited from January 2014 to May 2017 and the final date of follow-up was August 22, 2017. EXPOSURES: Acutely worsening respiratory symptoms in patients with COPD. MAIN OUTCOMES AND MEASURES: The primary outcome was pulmonary embolism diagnosed within 48 hours of admission. Key secondary outcome was pulmonary embolism during a 3-month follow-up among patients deemed not to have venous thromboembolism at admission and who did not receive anticoagulant treatment. Other outcomes were venous thromboembolism (pulmonary embolism and/or deep vein thrombosis) at admission and during follow-up, and 3-month mortality, whether venous thromboembolism was clinically suspected or not. RESULTS: Among 740 included patients (mean age, 68.2 years [SD, 10.9 years]; 274 women [37.0%]), pulmonary embolism was confirmed within 48 hours of admission in 44 patients (5.9%; 95% CI, 4.5%-7.9%). Among the 670 patients deemed not to have venous thromboembolism at admission and who did not receive anticoagulation, pulmonary embolism occurred in 5 patients (0.7%; 95% CI, 0.3%-1.7%) during follow-up, including 3 deaths related to pulmonary embolism. The overall 3-month mortality rate was 6.8% (50 of 740; 95% CI, 5.2%-8.8%). The proportion of patients who died during follow-up was higher among those with venous thromboembolism at admission than the proportion of those without it at admission (14 [25.9%] of 54 patients vs 36 [5.2%] of 686; risk difference, 20.7%, 95% CI, 10.7%-33.8%; P

Background: Clinical scoring systems for pulmonary embolism (PE) screening have low specificity and contribute to CT pulmonary angiogram (CTPA) overuse. We assessed whether deep learning models using an existing and routinely collected data modality, electrocardiogram (ECG) waveforms, can increase specificity for PE detection. Methods: We use clinical variables, annotated CTPAs, and ECG waveform and morphological parameter data from five hospitals to conduct a retrospective cohort study and develop three models to predict PE likelihood: an ECG model using only ECG waveform data, an EHR model using tabular clinical data, and a Fusion model integrating tabular clinical data and an embedded representation of the ECG waveform. We benchmark the best model against four clinical scores: Wells’ Criteria, Revised Geneva Score, Pulmonary Embolism Rule-Out Criteria, and 4-Level Pulmonary Embolism Clinical Probability Score. Finally, we investigate model robustness through feature sensitivity analyses and assess for demographic subgroup performance parity. Findings: We create a dataset linking 23,793 CTPAs (10·0% PE-positive) and 320,746 ECGs from 21,183 patients for model development and testing. We find that a Fusion model (area under receiver-operating characteristic [AUROC] 0·81 ± 0·01) outperforms both the ECG model (AUROC 0·59 ± 0·01) and EHR model (AUROC 0·65 ± 0·01). On a sample of 100 patients from the test set, the Fusion model has greater specificity (0·18) and performance (AUROC 0·84 ± 0.01) than the all four clinical criteria (AUROC 0·50-0·58, specificity 0·00-0·05). The model also retains superiority over clinical scores in feature sensitivity analyses (AUROC 0·66 to 0·84) and achieves comparable performance across different sex (AUROC 0·81) and racial (AUROC 0·77 to 0·84) subgroups. Interpretation: Integration of electrocardiogram waveforms with traditional clinical variables synergistically increases prediction performance and specificity for PE detection in those who are at least at moderate suspicion for PE. Funding: National Center for Advancing Translational Sciences, National Institutes of Health. Declaration of Interest: All authors declare no competing interests with this study. Ethical Approval: The study was approved by the Mount Sinai Institutional Review Board.

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 Pulmonary embolism (PE) is the third most common cardiovascular syndrome with an average annual incidence rate of 77 per 100,000 population in the worldwide. The diagnose algorithms for suspected PE are generally include clinical scoring assessment and plasma D-dimer evaluation, patients with high risk of PE require computed tomographic pulmonary angiogram (CTPA) detection for confirmation. Methods In this retrospective analysis, 1035 patients with suspected PE were recruited. All the patients were clinically received simplified Geneva score (SGS) pre-test, determination of plasma D-dimer level, and CTPA detection. All enrolled patients were grouped according to the CTPA results: PE patients and non-PE patients. Then, receiver operating characteristic (ROC) curve were constructed to determine the optimal D-dimer cutoff point value which is based on Yonden’s index (YI). Results 294 (28.4%) patients were confirmed with PE and 741(71.6%) individuals were regarded as non-PE cases by CTPA detection. Using the SGS pre-test, 829 (80.1%) patients were classified PE-unlikely (SGS ≤ 2) and 206 (19.9%) patients were PE-likely (SGS ≥ 3). Patients with D-dimer levels above 1.96 mg/L had a significant risk to suffer from PE (area under curve (AUC), 0.707; 95% CI, 0.678–0.735; p

Introduction Pulmonary embolism (PE) remains a frequent complication in patients with chronic obstructive pulmonary disease (COPD). It is unclear that the extent to which the traditional risk stratifying scores for PE are accurate in this population. Methods Cross-sectional study of adult patients with COPD and suspected PE included in an Institutional Registry of Thromboembolic Disease at a tertiary teaching hospital in the city of Buenos Aires, Argentina. We estimated the area under the receiver operating characteristic curves (AU-ROC), sensitivity and specificity of the Wells and Geneva scores using a positive computed tomography angiography as the gold standard for PE. We also estimated the sensitivity and specificity for the presence of isolated worsening of dyspnea at presentation, without other cardinal symptoms of acute exacerbation of COPD. Results A total of 168 patients were included, of which 22% had confirmed PE. The AUC was 0.66 (95% CI 0.56-0.76) and 0.56 (95% CI 0.45-0.67) for the Wells and Geneva, respectively. Considering the most widely used cutoff points, the sensitivity and specificity were 24% and 90% for the Wells and 59% and 43% for the Geneva score, respectively. Isolated worsening of dyspnea on presentation had a sensitivity of 92% and specificity of 37%. Conclusions Both Wells and Geneva scores exhibit poor diagnostic accuracy for the diagnosis of PE in patients with COPD. The presence of isolated worsening of dyspnea on presentation could be an easy to identify criteria for the initial triage in this population. Further validation of our findings remains warranted.

Background: The aim of the present study was to evaluate the utilization and diagnostic yields of CT pulmonary angiography (CTPA)using the Revised Geneva score and Wells’ criteria, in patients with suspected pulmonary embolism (PE). Methods: One hundred and twelve adult patients underwent CTPA for suspected PE were participated in this study. The outcome was positive or negative CTPA for PE. Revised Geneva and Wells’ scores were calculated. The relationship between the results obtained rom these two scores and the available risk factors were compared. Descriptive analysis such as frequency and mean as well as analytical statistics including chi-square were done. The data analysis was performed using SPSS (v. 22). Results: In this study, according to the Wells’ criteria calculated for the patients, 33.9% of the patients had low clinical, 56.3% intermediate and 9.8% high clinical probability. Among the 11 high clinical patients, 9(81.8%) were CTPA positive. Based on the revised Geneva score, 65 patients (58%) had low clinical, 36 (32.1%) intermediate and 11(9.8%) high clinical probability. Among the 1 high clinical patients, 8 were CTPA positive. Positive predictive value of the low clinical patients based on Wells’ criteria and the revised Geneva score was 18.4% and 30.8%, respectively. Also, positive predictive value for high clinical probability of Wells’ criteria and the revised Geneva score was 81.8% and 72.8% respectively. Conclusion: Under/overuse of CTPA in diagnosing PTE is a common problem especially in university hospitals. It is possible to avoid unnecessary CTPA requests using scholarly investigations and more accurate clinical risk assessments.

To assess the sensitivities of the Wells score (WS) and the revised Geneva score (RGS) and their prognostic values in the diagnosis of pulmonary embolism (PE) in the Japanese population.We conducted a retrospective chart review of patients with PE aged 16 years or older who were assessed between December 2008 and August 2014. Patients were divided into the PE unlikely and PE likely groups according to the WS and PE unlikely and PE likely groups according to the RGS. We also described the characteristics and three-month mortality of the patients. Univariate predictors with p0.05 were included in the multiple regression model. Fisher׳s exact test and Student׳s t-test were used for categorical and continuous variables, respectively.PE was confirmed in 53 patients, and seven (13%) patients died within 3 months. The mean age was 66.0 ± 14.4 years. There were 32 female patients (60.4%). The RGS had a higher sensitivity than the WS (20.8% vs. 15.1%, P0.01), although both scores had low yields. Mortality rate was significantly higher in patients with syncope than in those without (33.3% vs. 7.3%, respectively; P = 0.039). After age and sex adjustments, the presence of syncope showed a statistically significant association with mortality. The mortality rate did not significantly differ between the two groups categorized according to the WS (17.4% vs. 0%; P = 0.58) and RGS (21.7% vs. 14.3%; P = 1.00).WS and RGS had low sensitivity in the diagnosis of PE and had limited prognostic values in a Japanese community hospital setting. Promoting awareness about the risk of mortality in patients with PE, especially those with syncope, is necessary.

Hypothesis Beta-blockers (BBs) lower the heart rate, which may mask the diagnosis of pulmonary embolism (PE) since one of the main clinical diagnoses of PE is tachycardia. The endpoint of our retrospective study is to determine if the pre-existing use of (BB) significantly affects the utility of these scoring criteria in diagnosing PE. Introduction Diagnosing PE is a challenge because of the non-specificity of its symptoms and signs. The initial step is to assess the patient’s likelihood of having a PE. This involves using a scoring system to stratify patients into different levels of risk of having PE (for example, as ‘low,’ ‘moderate,’ or ‘high’ risk). Some of the commonly used criteria are Wells’ Score, Geneva Score, and Pulmonary Embolism Rule-out Criteria (PERC) Rule (Charlotte Rule). Methodology This retrospective study was conducted at St. Francis Medical Center. Subjects were taken from a patient population with a new diagnosis of PE (between 2010 and 2017) on the basis of computed tomography angiography (CTA) of the chest. Patients with sepsis or septic shock, heart block, atrioventricular (AV) nodal ablation, pacemaker placement, or taking more than one AV nodal blocker were excluded from the study. Subjects were categorized on the basis of beta-blocker consumption. Result Out of a total of 170 cases, 71 patients were taking beta-blockers and 99 patients were not taking beta-blockers. Among the participants taking BBs, 30.4% had a heart rate

Pulmonary embolism onset is frequently neglected due to the non-specific character of its symptoms. Pocket-size imaging devices (PSID) present an opportunity to implement imaging diagnostics into conventional physical examination. The aim of this study was to test the hypothesis that supplementation of the initial bedside assessment of patients with suspected pulmonary embolism (PE) with four-point compression venous ultrasonography (CUS) and right ventricular size assessment with the use of PSID equipped with dual probe could positively influence the accuracy of clinical predictions. A single-centre, prospective analysis was conducted on 100 patients (47 men, mean age 68 ± 13 years) with suspected PE. Clinical assessment on the basis of Wells and revised Geneva score and physical examination were supplemented with CUS and RV measurements by PSID. The mean time of PSID scanning was 4.9 ± 0.8 min and was universally accepted by the patients. Fifteen patients had deep venous thrombosis and RV enlargement was observed in 59 patients. PE was confirmed in 24 patients. If the both CUS was positive and RV enlarged, the specificity was 100% and sensitivity 54%, ROC AUC 0.771 [95% CI 0.68–0.85]. The Wells rule within our study population had the specificity of 86% and sensitivity of 67%, ROC AUC 0.776 (95% CI 0.681–0.853, p

BACKGROUND: The assessment of clinical guideline adherence for the evaluation of pulmonary embolism (PE) via computed tomography pulmonary angiography (CTPA) currently requires either labor-intensive, retrospective chart review or prospective collection of PE risk scores at the time of CTPA order. The recording of clinical data in a structured manner in the electronic health record (EHR) may make it possible to automate the calculation of a patient’s PE risk classification and determine whether the CTPA order was guideline concordant. OBJECTIVES: The objective of this study was to measure the performance of automated, structured-data-only versions of the Wells and revised Geneva risk scores in emergency department encounters during which a CTPA was ordered. The hypothesis was that such an automated method would classify a patient’s PE risk with high accuracy compared to manual chart review. METHODS: We developed automated, structured-data-only versions of the Wells and revised Geneva risk scores to classify 212 emergency department (ED) encounters during which a CTPA was performed as “PE Likely” or “PE Unlikely.” We then combined these classifications with D-dimer ordering data to assess each encounter as guideline concordant or discordant. The accuracy of these automated classifications and assessments of guideline concordance were determined by comparing them to classifications and concordance based on the complete Wells and revised Geneva scores derived via abstractor manual chart review. RESULTS: The automatically derived Wells and revised Geneva risk classifications were 91.5% and 92% accurate compared to the manually determined classifications, respectively. There was no statistically significant difference between guideline adherence calculated by the automated scores as compared to manual chart review (Wells: 70.8 vs. 75%, p = 0.33 | Revised Geneva: 65.6 vs. 66%, p = 0.92). CONCLUSION: The Wells and revised Geneva score risk classifications can be approximated with high accuracy using automated extraction of structured EHR data elements in patients who received a CTPA. Combining these automated scores with D-dimer ordering data allows for the automated assessment of clinical guideline adherence for CTPA ordering in the emergency department, without the burden of manual chart review.

Background Guidelines suggest anticoagulation of patients with high pretest probability of pulmonary embolism (PE) while awaiting diagnostic test results (preemptive anticoagulation). Data relevant to the practice of preemptive anticoagulation are not available. Methods We reviewed 3,500 consecutive patients who underwent CT pulmonary angiography (CTPA) at two EDs. We classified the pretest probability for PE using the revised Geneva Score (RGS) as low (RGS 0-3), intermediate (RGS 4-10), or high (RGS 11-18). We classified patients with a high pretest probability of PE as receiving preemptive anticoagulation if therapeutic anticoagulation was given before CTPA completion. Patients with a high bleeding risk and those receiving treatment for DVT before CTPA were excluded from the preemptive anticoagulation analysis. We compared the time elapsed between ED registration and CTPA completion for patients with a low, intermediate, and high pretest probability for PE. Results We excluded three of 3,500 patients because CTPA preceded ED registration. Of the remaining 3,497 patients, 167 (4.8%) had a high pretest probability for PE. After excluding 29 patients for high bleeding risk and 21 patients who were treated for DVT prior to CTPA, only two of 117 patients (1.7%) with a high pretest probability for PE received preemptive anticoagulation. Furthermore, 37 of the remaining 115 patients (32%) with a high pretest probability for PE had a preexisting indication for anticoagulation but did not receive preemptive anticoagulation. The time from ED registration to CTPA completion did not differ based on the pretest probability of PE. Conclusions Physicians rarely use preemptive anticoagulation in patients with a high pretest probability for PE. Clinicians do not expedite CTPA examinations for patients with a high pretest probability for PE.

Objectives To evaluate and to compare the predictive accuracy of the Wells score and the revised Geneva scores for the diagnosis of pulmonary embolism in the pregnant and postpartum population. Study design All pregnant or post-partum patients with a suspected PE and for whom a diagnostic imaging testing was performed (VQ scintigraphy or computed tomography pulmonary angiography) over a 3-year period were included in the study. The Wells and Revised Geneva Scores were calculated on the same cohort of patients and dichotomized into low and intermediate/high probability groups. The sensitivities and specificities were calculated. Overall accuracy was determined using receiver operator characteristic curve analysis. Results A total of 103 patients were included. The overall prevalence of PE was 26.2% (27/103). Using the Wells Score, the prevalence of patients with PE in the low, intermediate and high probability categories was 20.5%, 43.5% and 50% respectively. Using the Revised Geneva Score, the prevalence of patients with PE in the low, intermediate and high probability categories was 17%, 36.2 and 33.3% respectively. In low risk groups of the Wells score and the simplified revised Geneva score the prevalence of PE was not statistically significantly different: respectively: 20.5% and 17.5% (p = 0,232). The agreement on clinical assessment using the Wells score and using the revised Geneva score was weak (κ coefficient = 0.154). In total, 26 (25.2%) patients were classified differently using the 2 scores. There was no significant difference in the overall accuracies of the Wells (0.67, 95% CI 0.54–0.79) and Revised Geneva Scores (0.64, 95% CI 0.52–0.76) as determined by the area under the ROC curves (P = 0.628). The sensitivity, specificity, PPV and NPV of the Wells score and the revised Geneva score were respectively: 40.7%, 81.5%, 44%, 79.4% and 62.9%, 59.2%, 35.4%, 81.8%. Conclusion(s) The Wells score and the revised Geneva seems not to be valuable in the pregnant and post partum population. A specific risk score of PE for pregnant and postpartum population is needed to reduce the rate of unnecessary imaging studies, especially in this specific population were the use of radiation and contrast agent is problematic.

Background Evidence suggests the potential overuse of computed tomography pulmonary angiography (CTPA) in patients with suspected pulmonary thromboembolism (PTE) in the absence of consistent use of pre-test clinical prediction rules and D-dimer assays. Aim To evaluate use and diagnostic utility of clinical prediction rules and D-dimer assay in patients with suspected PTE and quantify potentially avoidable overuse of CTPA in low risk patients. Methods A total of 344 consecutive patients undergoing CTPA at a tertiary hospital was studied with regards to the use of D-dimer assays and clinical prediction rules for PTE. For each patient, a modified Wells score (mWS), revised Geneva score and PISA model were calculated retrospectively; performance characteristics for each rule for PTE were determined with reference to results of CTPA. Results for the mWS and D-dimer assays (when performed) were used to estimate the overuse of CTPA according to risk category. Results Use of a clinical prediction rule was documented in only 5.0% of cases. Of 269 low-risk patients who had a calculated mWS ≤4, only 64 (23.8%) had a D-dimer assay performed, with 30 (11.1%) having a PTE on CTPA. Among 75 patients with an mWS >4, 23 (30.7%) had a PTE on CTPA (P 4 had the highest positive predictive value (31.0%) for PTE; all rules demonstrated similar negative predictive values for low-risk scores (87–89%). After adjusting for an 11% false negative rate for PTE in patients with low-risk mWS, overuse of CTPA was reported in up to 190 (55.2%) patients. Conclusion More than 50% of patients with suspected PTE may be subject to unwarranted use of CTPA in the absence of pre-test clinical prediction rules coupled with D-dimer assays.

Įvadas: nėra būdingų klinikinių simptomų, fizinio ištyrimo ir laboratorinių tyrimų duomenų, kurie patikimai atmestų plaučių arterijos trombinę emboliją. Klinikinį ligonio, kuriam įtariama PATE, įvertinimą gali palengvinti klinikinės PATE tikimybės skalės. Tikslas: nustatyti ūminės plaučių arterijos trombinės embolijos (PATE) D-dimerų koncentracijos, Wells ir modifikuotos Geneva skalių bei jų kombinacijų su D-dimerų koncentracija prognostines vertes senyvo amžiaus (≥ 65 m.) pacientams. Metodika: retrospektyviai analizuotos 2013 m. – 2014 m. laikotarpiu Vilniaus universiteto ligoninės Santaros klinikų priėmimo skyriuje dėl įtariamos ūminės PATE hospitalizuotų pacientų ligos istorijos. Rinkti demografiniai, anamnezės, apžiūros, laboratoriniai ir KT angiografijos duomenys. Remiantis klinikine išraiška, apskaičiuotos Wells ir modifikuotos Geneva skalių teigiamos prognostinės vertės bei kiekvienos iš jų kombinacijos su D-dimerų koncentracija neigiamos prognostinės vertės < 65 m. ir ≥ 65 m. amžiaus pacientams. Duomenys apdoroti Microsoft Excel, SPSS V.22, MedCalc 11.5.0 programomis. Pasirinktas reikšmingumo lygmuo p < 0,05. Rezultatai: tyrimo imtis 516 pacientų: ≥ 65 m. amžiaus grupę sudarė 330 (61,4 proc.), < 65 m. amžiaus grupę – 186 (38,6 proc.) pacientai. KT angiografijos metu ūmi PATE patvirtinta 150 (45,5 proc.) ≥ 65 m. amžiaus ir 69 (37 proc.) < 65 m. amžiaus pacientams. ≥ 65 m. grupėje Wells skalės teigiama prognostinė vertė 74,3 proc. (95% CI: 65,06 – 82,20), modifikuotos Geneva skalės – 49,6 proc. (95% CI: 43,49 – 55,77), p < 0,001. < 65 m. amžiaus grupėje – 66,1 proc. (95% CI: 52,99 77,67) ir 50,5 proc. (95% CI: 40,36 – 60,60), p < 0,001. Neigiama prognostinė D-dimerų vertė ≥ 65 m. grupėje 96,30 proc. (95% CI: 81,03 – 99,91), < 65 m. grupėje 95,74 proc. (95% CI: 85,46 – 99,48). D-dimerų ir Wells bei D-dimerų ir modifikuotos Geneva testų kombinacijos neigiama prognostinė vertė ≥ 65 m. grupėje: 100,00 proc. (95% CI: 84,56 – 100,00) ir 100,00 proc. (95% CI: 59,04 – 100,00); < 65 m. amžiaus grupėje 100,00 proc. (95% CI: 91,40 – 100,00) ir 100,00 proc. (95% CI: 89,11 – 100,00). Išvados: Wells skalės teigiama prognostinė vertė aukštesnė nei modifikuotos Geneva skalės teigiama prognostinė vertė. Atmetant PATE diagnozę D-dimerų ir Wells bei D-dimerų ir modifikuotos Geneva skalių kombinacijos neigiama prognostinė vertė aukštesnė nei vien D-dimerų koncentracijos neigiama prognostinė vertė.

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.

Objectives Pulmonary embolism (PE) is seven times more common in cancer patients than non-cancer patients. Since the existing clinical prediction rules (CPRs) were validated predominantly in a non-cancer population, we decided to look at the utility of arterial blood gas (ABG) analysis and D-dimer in predicting PE in cancer patients. Methods Electronic medical records were reviewed between December 2005 and November 2010. A total of 177 computed tomography pulmonary angiograms (CTPAs) were performed. We selected 104 individuals based on completeness of laboratory and clinical data. Patients were divided into two groups, CTPA positive (patients with PE) and CTPA negative (PE excluded). Wells score, Geneva score, and modified Geneva score were calculated for each patient. Primary outcomes of interest were the sensitivities, specificities, positive, and negative predictive values for all three CPRs. Results Of the total of 104 individuals who had CTPAs, 33 (31.7%) were positive for PE and 71 (68.3%) were negative. There was no difference in basic demographics between the two groups. Laboratory parameters were compared and partial pressure of oxygen was significantly lower in patients with PE (68.1 mmHg vs. 71 mmHg, p = 0.030). Clinical prediction rules showed good sensitivities (88-100%) and negative predictive values (93-100%). An alveolar-arterial (A-a) gradient > 20 had 100% sensitivity and negative predictive values. Conclusions CPRs and a low A-a gradient were useful in excluding PE in cancer patients. There is a need for prospective trials to validate these results.