Diagnostic Strategies in Pulmonary Embolism.

Key to the diagnosis of pulmonary embolism (PE) is a careful bedside evaluation. After this, there are three further diagnostic steps. In all patients, estimation of the clinical probability of PE is performed. The other two steps are measurement of D-dimer when indicated and chest imaging when indicated. The clinical probability of PE is estimated at low, moderate, or high. The prevalence of PE is less than 15% among patients with low clinical probability, 15 to 40% with moderate clinical probability, and >40% in patients with high clinical probability. Clinical gestalt has been found to be very useful in estimating probability of PE. However, clinical prediction rules, such as Wells criteria, the modified Geneva score, and the PE rule out criteria have been advocated as adjuncts. In patients with high clinical probability, the high prevalence of PE can lower the D-dimer negative predictive value, which could increase the risk of diagnostic failure. Consequently, patients with high probability for PE need to proceed directly to chest imaging, without prior measurement of D-dimer level. Key studies in determining which low to moderate probability patients require chest imaging are the Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism (ADJUST-PE), the Simplified diagnostic management of suspected pulmonary embolism (YEARS), and the Pulmonary Embolism Graduated D-Dimer trials. In patients with low clinical probability, PE can be excluded without imaging studies if D-dimer is less than 1,000 ng/mL. In patients in whom there is not a low likelihood for PE, this can be excluded without imaging studies if the D-dimer is below the age-adjusted threshold.

Assessment of the Utilization of Validated Diagnostic Predictive Tools and D-Dimer in the Evaluation of Pulmonary Embolism: A Single-Center Retrospective Cohort Study from a Public Hospital in New York City.

INTRODUCTION: A significant increase in the use of computed tomography with pulmonary angiography (CTPA) for the diagnosis of pulmonary embolism (PE) has been observed in the past twenty years. We aimed to investigate whether the validated diagnostic predictive tools and D-dimers were adequately utilized in a large public hospital in New York City. METHODS: We conducted a retrospective review of patients who underwent CTPA for the specific indication of ruling out PE over a period of one year. Two independent reviewers, blinded to each other and to the CTPA and D-dimer results, estimated the clinical probability (CP) of PE using Well's score, the YEARS algorithm, and the revised Geneva score. Patients were classified based on the presence or absence of PE in the CTPA. RESULTS: A total of 917 patients were included in the analysis (median age: 57 years, female: 59%). The clinical probability of PE was considered low by both independent reviewers in 563 (61.4%), 487 (55%), and 184 (20.1%) patients based on Well's score, the YEARS algorithm, and the revised Geneva score, respectively. D-dimer testing was conducted in less than half of the patients who were deemed to have low CP for PE by both independent reviewers. Using a D-dimer cut-off of <500 ng/mL or the age-adjusted cut-off in patients with a low CP of PE would have missed only a small number of mainly subsegmental PE. All three tools, when combined with D-dimer < 500 ng/mL or 95%. CONCLUSION: All three validated diagnostic predictive tools were found to have significant diagnostic value in ruling out PE when combined with a D-dimer cut-off of <500 ng/mL or the age-adjusted cut-off. Excessive use of CTPA was likely secondary to suboptimal use of diagnostic predictive tools.

Comparing 'clinical hunch' against clinical decision support systems (PERC rule, wells score, revised Geneva score and YEARS criteria) in the diagnosis of acute pulmonary embolism.

BACKGROUND: Pulmonary embolism (PE) is a common and potentially life-threatening condition. Since it is considered a 'do not miss' diagnosis, PE tends to be over-investigated beyond the evidence-based clinical decision support systems (CDSS), which in turn subjects patients to unnecessary radiation and contrast agent exposure with no apparent benefits in terms of outcome. The purpose of this study was to evaluate the yield of 'clinical hunch' (gestalt) and four CDSS: the PERC Rule, Wells score, revised Geneva score, and Years criteria. METHODS: A review was conducted on the Electronic Medical Records (EMR) of 1566 patients from the Emergency Department at a tertiary teaching hospital who underwent CTPA from the 1st of January 2018 to the 31st of December 2019. The scores for the four CDSS were calculated retrospectively from the EMR data. We considered that a CTPA had been ordered on a clinical hunch when there was no mention of CDSS in the EMR, and no D-dimer test. A bypass of CDSS was confirmed when any step of the diagnostic algorithms was not followed. RESULTS: Of the total 1566 patients who underwent CTPA, 265 (17%) were positive for PE. The diagnosis yield from the five decision groups (clinical hunch and four CDSS) was as follows-clinical hunch, 15%; PERC rule, 18% (6% when bypassed); Wells score, 19% (11% when bypassed); revised Geneva score, 26% (13% when bypassed); and YEARS criteria, 18% (6% when bypassed). CONCLUSION: Clinicians should trust the evidence-based clinical decision support systems in line with the international guidelines to diagnose PE.

Adherence to risk-assessment protocols to guide computed tomography pulmonary angiography in patients with suspected pulmonary embolism.

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.

CT pulmonary angiography appropriateness in a single emergency department: does the use of revised Geneva score matter?

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.

Comparison of the Wells score and the revised Geneva score as a tool to predict pulmonary embolism in outpatients over age 65.

TITLE: Comparison of the Wells score and the revised Geneva score as a tool to predict pulmonary embolism in outpatients over 65 years of age. INTRODUCTION: The incidence and mortality of pulmonary embolism (PE) is high in the elderly. The Wells score (SW) and the revised Geneva score (RGS) have been validated in patient populations with a large age range. The aim of this study was to compare the predictive accuracy of these two scores in diagnosis of PE in patients over 65 years of age. METHOD: A prospective multicentre study (nine French and three Belgian centres) was conducted at the same time as the PERCEPIC study. A total of 1757 patients admitted with suspected PE were included and divided into two groups according to age (≥65 years or <65 years). The pre-test probability of PE was assessed prospectively for the RGS. The SW was calculated retrospectively. The predictive accuracy of the two scores was compared by the area under the curve (AUC) of the ROC curves. RESULTS: The overall prevalence of PE was 11.3%. The prevalence among patients aged ≥65 in the low, moderate and high pre-test probability groups, evaluated using the WS and was respectively 13.5% (CI 95%: CI 9.9-17.3), 28.2% (CI 22.1-34.3), 50% (CI 26-74) and 8.1% (CI 3.2-12.9), 22.3% (CI 18.2-26.3), 43.7% (CI 25.6-61.9) using the RGS. The AUC for the WS and RGS for patients aged ≥65 was 0.632 (CI 0.574-0.691) and 0.610 (CI 0.555-0.666). The difference between the AUCs was not statistically significant (p = .441). CONCLUSION: In the population for this study, the WS and RGS have the same PE diagnostic accuracy in patients over age 65. This result should be validated in a prospective study that directly compares these scores.

The diagnostic value of D-dimer with simplified Geneva score (SGS) pre-test in the diagnosis of pulmonary embolism (PE).

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 < 0.05). Meanwhile, in patients with SGS ≥ 3, the D-dimer cutoff point value moved to 2.2 mg/L (AUC, 0.644; 95% CI, 0.574-0.709; p < 0.05). CONCLUSION: D-dimer test in combination with SGS pre-test could improve the accuracy of PE diagnosis. Patients with D-dimer levels over 1.96 mg/L (4 times of the normal level) have a significant risk for PE. In patients with SGS ≥ 3, the D-dimer cutoff point concentration for PE risk moves to the levels of 2.2 mg/L.

Wells and Geneva Scores Are Not Reliable Predictors of Pulmonary Embolism in Critically Ill Patients: A Retrospective Study.

BACKGROUND: Critically ill patients are at high risk for pulmonary embolism (PE). Specific PE prediction rules have not been validated in this population. The present study assessed the Wells and revised Geneva scoring systems as predictors of PE in critically ill patients. METHODS: Pulmonary computed tomographic angiograms (CTAs) performed for suspected PE in critically ill adult patients were retrospectively identified. Wells and revised Geneva scores were calculated based on information from medical records. The reliability of both scores as predictors of PE was determined using receiver operating characteristic (ROC) curve analysis. RESULTS: Of 138 patients, 42 (30.4%) were positive for PE based on pulmonary CTA. Mean Wells score was 4.3 (3.5) in patients with PE versus 2.7 (1.9) in patients without PE (P < .001). Revised Geneva score was 5.8 (3.3) versus 5.1 (2.5) in patients with versus without PE (P = .194). According to the Wells and revised Geneva scores, 56 (40.6%) patients and 49 (35.5%) patients, respectively, were considered as low probability for PE. Of those considered as low risk by the Wells score, 15 (26.8%) had filling defects on CTA, including 2 patients with main pulmonary artery embolism. The area under the ROC curve was 0.634 for the Wells score and 0.546 for the revised Geneva score. Wells score >4 had a sensitivity of 40%, specificity of 87%, positive predictive value of 59%, and negative predictive value of 77% to predict risk of PE. CONCLUSIONS: In this population of critically ill patients, Wells and revised Geneva scores were not reliable predictors of PE.

A comparative analysis of the diagnostic performances of four clinical probability models for acute pulmonary embolism in a sub-Saharan African population: a cross-sectional study.

BACKGROUND: The diagnosis of acute pulmonary embolism (PE) is one of the most challenging in emergency settings where prompt and accurate decisions need to be taken for life-saving purposes. Here, the assessment of the clinical probability of PE is a paramount step in its diagnosis. Although clinical probability models (CPM) for PE are routinely used in emergency departments (EDs) of low-resource settings, few studies have cited their diagnostic performances in sub-Saharan Africa (SSA). We aimed to comparatively assess the accuracy of four CPM in the diagnosis of acute PE in sub-Saharan Africans. METHODS: We carried out a cross-sectional study to compare the sensitivity, specificity, positive and negative predictive values and accuracy of four CPM namely; the Wells, simplified Wells, revised Geneva and the simplified revised Geneva (SRG) Scores to computed tomography pulmonary angiography (CTPA) in all adults patients with suspected PE admitted to the EDs of the Gynaeco-obstetric and Paediatric Hospital of Yaoundé and the Yaoundé Central Hospital in Cameroon between January 1, 2017 and April 30, 2018. RESULTS: In total, we enrolled 30 patients with clinical suspicion of acute PE. PE was confirmed on CTPA in 16 (53.3%) cases. Their mean age was 53.7 ± 15.5 years and 36.7% were males. All four scores had a diagnostic performance superior to 50% in all criteria assessed. The simplified Wells score had the highest sensitivity (62.5%) followed by the Wells score (56.3%). The SRG score had the highest specificity (71.4%). The score with highest PPV was the SRG score (66.7%) and that with the highest NPV was the Wells score (56.3%). Overall the models with the highest accuracies were the Wells and SRG scores (60% for each). CONCLUSION: All CPM had a suboptimal diagnostic performance, perhaps highlighting the need of a more optimal CPM for acute PE in SSA. However, the Wells and the SRG scores appeared to be most accurate than the other two scores in the ED. Hence, both or either of them may be used in first intention to predict PE and guide which ED patients should undergo further investigations in an emergency SSA setting.

Validity of four clinical prediction scores for pulmonary embolism in a sub-Saharan African setting: a protocol for a Cameroonian multicentre cross-sectional study.

INTRODUCTION: Pulmonary embolism poses one of the most challenging diagnoses in medicine. Resolving these diagnostic difficulties is more crucial in emergency departments where fast and accurate decisions are needed for a life-saving purpose. Here, clinical pretest evaluation is an important step in the diagnostic algorithm of pulmonary embolism. Although clinical probability scores are widely used in emergency departments of sub-Saharan Africa, no study has cited their diagnostic performance in this resource-constrained environment. This study will seek to assess the performance of four routinely used clinical prediction models in Cameroonians presenting with suspicion of pulmonary embolism at the emergency department. METHODS AND ANALYSIS: It will be a cross-sectional study comparing the sensitivity, specificity, positive and negative predictive values and accuracy of the Wells, Simplified Wells, Revised Geneva and the Simplified Revised Geneva Scores to CT pulmonary angiography as gold standard in all consecutive consenting patients aged above 15 years admitted for clinical suspicion of pulmonary embolism to the emergency departments of seven major referral hospitals of Cameroon between 1 July 2019 and 31 December 2020. The area under the receiver operating curve, calibration plots, Hosmer and Lemeshow statistics, observed/expected event rates, net benefit and decision curve will be measured of each the clinical prediction test to ascertain the clinical score with the best diagnostic performance. ETHICS AND DISSEMINATION: Clearance has been obtained from the Institutional Review Board of the Faculty of medicine and biomedical sciences of the University of Yaounde I, Cameroon and the directorates of all participating hospitals to conduct this study. Also, informed consent will be sought from each patient or their legal next of kin and parents for minors, before enrolment into this study. The final study will be published in a peer-review journal and the findings presented to health authorities and healthcare providers.

Use of a three-tiered clinical decision rule to quantify unnecessary radiological investigation of suspected pulmonary embolism.

BACKGROUND: Clinical decision rules for suspected pulmonary embolism are proposed to identify patients suitable for discharge without radiological investigation. Their use varies between institutions. AIMS: To quantify unnecessary radiological investigations for suspected pulmonary embolism (PE) as defined by a newly proposed three-tiered clinical decision rule incorporating the revised Geneva score, Pulmonary Embolism Rule-Out Criteria and D-dimer. To quantify missed diagnosis of PE if the proposed clinical decision rule were followed. METHODS: A retrospective audit was conducted; applying the proposed clinical decision rule to 584 emergency department (ED)-based encounters at the Royal Adelaide Hospital from May to November 2015. Encounters were confined to emergency presentations where suspected acute PE was investigated with computed tomography pulmonary angiography or ventilation-perfusion scanning; inpatient and follow-up studies were excluded. Sensitivity, specificity, positive predictive value and negative predictive value of the proposed clinical decision rule within the studied population were calculated. RESULTS: Data were obtained for 584 patient encounters where suspected PE was investigated radiologically. Applied retrospectively, the proposed clinical decision rule had a negative predictive value of 97.7% and a sensitivity of 98.5% for radiologically proven PE; 9.2% of scans could have been avoided. One case of PE would have been missed; a false-negative rate of 1.5%. CONCLUSION: Retrospective application of the proposed clinical decision rule to the studied cohort indicates at least 9% of radiological investigations were unnecessary. A prospective study is needed to assess the safety and cost-effectiveness of applying such a pathway to all patients presenting to ED with suspected PE.

Effect of Beta-blockers on Tachycardia in Patients with Pulmonary Embolism.

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 <60 and 55.8% had a heart rate between 60 and 100. Conclusion BBs significantly obviate tachycardia in patients with PE. It falsely decreases the Wells' Score and the Geneva Score and results in the inappropriate fulfilling of PERC criteria.

Complex calculation or quick glance? Mean platelet volume - new predictive marker for pulmonary embolism.

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 (P<0.05) per contra to Geneva score (P>0.05). 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.

Overuse and underuse of pulmonary CT angiography in patients with suspected pulmonary embolism.

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.

Brief cardiovascular imaging with pocket-size ultrasound devices improves the accuracy of the initial assessment of suspected pulmonary embolism.

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 < 0.0001). Similar values calculated for the revised Geneva score were as follows: specificity 58% and sensitivity 63%, ROC AUC 0.664 (95% CI 0.563-0.756, p = 0.0104). Supplementing the revised Geneva score with additional criteria of CUS result and RV measurement resulted in significant improvement of diagnostic accuracy. The difference between ROC AUCs was 0.199 (95% Cl 0.0893-0.308, p = 0.0004). Similar modification of Wells score increased ROC AUC by 0.133 (95% CI 0.0443-0.223, p = 0.0034). Despite the well-acknowledged role of the PE clinical risk assessment scores the diagnostic process may benefit from the addition of basic bedside ultrasonographic techniques.

[Predictive value of Wells Score, Revised Geneva Score combined with D-dimer for Pulmonary Embolism in patients with acute exacerbation of chronic obstructive pulmonary disease].

Objective: To evaluate the predictive value of Wells score, revised Geneva score combined with D-dimer for the risk of pulmonary embolism in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). Methods: In this study, 234 AECOPD patients underwent CT pulmonary angiography from March 1, 2013 to December 31, 2015 in the First Affiliated Hospital of Zhengzhou University. The basic data of the patients were collected and the patients were classified into AECOPD combined with pulmonary embolism group(pulmonary embolism group) and AECOPD group according to CT pulmonary angiography results. All patients were scored by Wells score and revised Geneva score. The receiver operating characteristic (ROC) curves were generated and the Z test was applied to evaluate the predictive value by comparing the area under the ROC curves (AUC). Results: Totally 32(13.7%) patients had pulmonary embolism out of the 234 AECOPD patients. The AUC by Wells score, revised Geneva score, D-dimer, Wells score + D-dimer, revised Geneva score + D-dimer were 0.869 (95% CI: 0.789-0.949), 0.710 (95% CI: 0.588-0.832), 0.866 (95% CI: 0.790-0.941), 0.926 (95% CI: 0.874-0.977), 0.855 (95% CI: 0.751-0.959). The AUC of Wells score and D-dimer were significantly greater than that of revised Geneva score (Z=2.14, 2.12, both P<0.05); the AUC of Wells score + D-dimer was significantly greater than revised Geneva score + D-dimer (Z=2.73, P<0.05). Conclusion: The predictive value of Wells score + D-dimer for pulmonary embolism in AECOPD patients is higher than revised Geneva score + D-dimer.

[Prevalence and severity of pulmonary embolism are dependent on clinical and paraclinical parameters : Analysis of 1,943 consecutive patients with CT pulmonary angiography]. / Prävalenz und Schwere der Lungenarterienembolie in Abhängigkeit von klinischen und paraklinischen Parametern : Analyse von 1943 konsekutiven Patienten mit CT-Pulmonalisangiographie.

BACKGROUND: Patients with pulmonary embolism (PE) have heterogeneous symptoms. Clinical scores and age-adjusted D­dimer should help clinicians to establish the correct diagnosis. METHODS: A cohort of 1,943 consecutive patients with positive D­dimer levels who were referred for CT pulmonary angiography (CTPA) over a period of 5 years to rule PE in or out were retrospectively analyzed. RESULTS: On CTPA n = 362 (19 %) had PE. The prevalence of PE increased stepwise with increasing D­dimer levels (prevalence of PE with 10 percentiles of D­dimers was: 3 %, 4 %, 7 %, 8 %, 8 %, 21 %, 20 %, 27 %, 37 %, 52 %; p < 0.001). D­dimers > 2.0 were significantly associated with PE (OR 7.17 95 % CI 5.27-9.76, p < 0.001). Chest discomfort and tachypnea showed no association with PE. Dyspnoea, pleuritic pain, and general fatigue showed significant associations with age: pleuritic chest pain was more frequent in patients aged < 76 years than in patients aged > 76 years (15 % vs 3 %; p < 0.001) and was highly significantly associated with PE (OR 4.99 95 % CI 2.83-8.81; p < 0.001). General fatigue was more prevalent in patients aged > 76 years (44 % vs 24 %; p < 0.001). PE patients with D­dimers > 6.0 mg/l were hemodynamically more compromised than patients with D­dimers < 6.0 mg/l: tachycardia 32 % vs 20 %, p = 0.015; right ventricular strain on echocardiography: 38 % vs 23 %, p = 0.003; right ventricular strain on ECG: 27 % vs 13 %; p  = 0.001; resuscitation 4 % vs 0 %, p = 0.003; lytic therapy 6 % vs 1 %, p = 0.014. CONCLUSION: The symptoms of PE patients are often vague. Particularly in older patients, fatigue may be the only symptom. The absolute level of D­dimers, particularly > 2.0 mg/l, is a strong predictor of PE. A D­dimer level > 6.0 mg/l is associated with more severe hemodynamic impairment in patients with PE.

Predictive value of revised Geneva score,ECG score and D-dimer in pulmonary embolism / 安徽医科大学学报

Objective To evaluate the value of revised Geneva score, Daniel ECG score and age-adjusted D-dimer for predicting pulmonary embolism(PE).Methods A total of 91 cases suspected as pulmonary embolism were collected, and 52 cases were diagnosed as pulmonary embolism by computed tomographic pulmonary angiography(CTPA) results.Receiver operating characteristic(ROC) curves and diagnostic test evaluation indexes were used to evaluate the probability of PE predicted by the revised Geneva score,Daniel ECG score, age-adjusted D-dimer and combination of these two clinical scores and age-adjusted D-dimer.Results The confirmed PE was 21.4% with a low probability(revised Geneva score 0~3 points),55.4% in intermediate probability(4~10 points),85.7% in high probability(score≥11 points).The prevalence of PE was 33.3% with a low clinical probability (Daniel ECG score<2 points)and 70.7% with a high clinical probability(Daniel ECG score≥2 points).The sensitivity and specificity of age-adjusted D-dimer in predicting pulmonary embolism were 92.3%,69.2%.The area under curve of the ROC curve(AUC)in the revised Geneva score and Daniel ECG score has no significant difference(Z=0.979).The negative predictive value of the revised Geneva score, Daniel ECG score combined with D-dimer in pulmonary embolism were 100.0% and 87.5%.Conclusion All of revised Geneva score, Daniel ECG score and age-adjusted D-dimer have certain predictive value on pulmonary embolism , and the revised Geneva score combined with age-adjusted D-dimer can be more safely exclude pulmonary embolism.

Comparison of the Wells score with the revised Geneva score for assessing suspected pulmonary embolism: a systematic review and meta-analysis.

The Wells score and the revised Geneva score are two most commonly used clinical rules for excluding pulmonary embolism (PE). In this study, we aimed to assess the diagnostic accuracy of these two rules; we also compared the diagnostic accuracy between them. We searched PubMed and Web of science up to April 2015. Studies assessed Wells score and revised Geneva score for diagnosis suspected PE were included. The summary area under the curve (AUC) and the 95 % confidence interval (CI) were calculated. Eleven studies were included in this meta-analysis. For Wells score, the sensitivity ranged from 63.8 to 79.3 %, and the specificity ranged from 48.8 to 90.0 %. The overall weighted AUC was 0.778 (95 % CI 0.740-0.818; Z = 9.88, P < 0.001). For revised Geneva score, the sensitivity ranged from 55.3 to 73.6 %. The overall weighted AUC was 0.693 (95 % CI 0.653-0.736; Z = 11.96, P < 0.001). 95 % CIs of two AUCs were not overlapped, which indicated Wells score was more accurate than revised Geneva score for predicting PE in suspected patients. Meta-regression showed diagnostic accuracy of these two rules was not related with PE prevalence. Sensitivity analysis by only included prospective studies showed the results were robust. Our results showed the Wells score was more effective than the revised Geneva score in discriminate PE in suspected patients.