Pulmonary embolism assessment of clinical probability and risk scores
Jump to navigation
Jump to search
 |
Resident Survival Guide |
|
Pulmonary Embolism Microchapters |
|
Diagnosis |
|---|
|
Pulmonary Embolism Assessment of Probability of Subsequent VTE and Risk Scores |
|
Treatment |
|
Follow-Up |
|
Special Scenario |
|
Trials |
|
Case Studies |
|
Pulmonary embolism assessment of clinical probability and risk scores On the Web |
|
FDA on Pulmonary embolism assessment of clinical probability and risk scores |
|
CDC on Pulmonary embolism assessment of clinical probability and risk scores |
|
Pulmonary embolism assessment of clinical probability and risk scores in the news |
|
Blogs on Pulmonary embolism assessment of clinical probability and risk scores |
Editor(s)-In-Chief: C. Michael Gibson, M.S., M.D. [1], The APEX Trial Investigators; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Rim Halaby, M.D. [3]
Overview
The diagnosis of pulmonary embolism (PE) is based primarily on the clinical assessment of the pretest probability of PE combined with diagnostic modalities such as spiral CT, V/Q scan, use of the D-dimer, and lower extremity ultrasound. Clinical prediction rules for PE include: the Wells score, the Geneva score and the PE rule-out criteria (PERC).
Assessment of Clinical Probability
A clinical prediction rule is a type of medical research study in which the researchers try to identify the best combination of signs, symptoms, and other findings to predict the probability of a specific disease or outcome.[1] Clinical prediction rules for PE include: the Wells score, the Geneva score and the PE rule-out criteria. Its noteworthy that the use of any clinical prediction rule is associated with reduction in recurrent thromboembolism.[2]
These clinical prediction rules, coupled with diagnostic tests, are used to identify patients who should be treated.
Supportive Trial Data
- Prospective Investigation On Pulmonary Embolism Diagnosis (PIOPED) investigators demonstrated that all patients with or without PE had abnormal V/Q scans of high, intermediate, or low probability (sensitivity, 98%; specificity, 10%). Furthermore, of the 116 patients with high-probability scans and definitive angiograms, only 88% had a PE. On the contrary, only a minority of patients with pulmonary embolism demonstrated high-probability scans (sensitivity, 41%; specificity, 97%). Similarly, of the 322 patients with intermediate-probability scans and definitive angiograms, only 33% had a PE. The majority of these patients demonstrated low to moderate clinical probability which required no further intervention.[3]
- Prospective multicenter outcome study by Musset et al, demonstrated that with-holding anticoagulation treatment in patients with low or intermediate clinical probability was safe as long as there was a negative spiral CT and negative ultrasonagraphy. Of the 1041 patients enrolled in the study, 525 were assessed as having low or intermediate clinical probability and 507 were not treated with anticoagulation. During a 3-month follow-up, only 9 patients experienced venous thromboembolism (1.8% [0.8-3.3]) and the diagnostic strategy proved inconclusive in 95 (9.1%) patients.[4][5]
Wells Score
The Wells score is a simple, commonly used clinical risk prediction tool to evaluate the need for further testing in patients suspected to have pulmonary embolism.[6][7][8][9]
Calculation of Wells Score
Pulmonary embolism Wells Score Calculator
| Variable | Wells Score[8] |
| Clinically suspected DVT (leg swelling, pain with palpation) | 3.0 |
| Alternative diagnosis is less likely than PE | 3.0 |
| Immobilization/surgery in previous four weeks | 1.5 |
| Previous history of DVT or PE | 1.5 |
| Tachycardia (heart rate more than 100 bpm) | 1.5 |
| Malignancy (treatment for within 6 months, palliative) | 1.0 |
| Hemoptysis | 1.0 |
Interpretation of Wells Score
Wells Criteria
Shown below is the pretest probability of PE according to Wells criteria.[8][9][10]
- Score >6.0: High probability (Rate of PE: ~66.7%)
- Score 2.0 to 6.0: Moderate probability (Rate of PE: ~20.5%)
- Score <2.0: Low probability (Rate of PE: ~3.6%)
Modified Wells Criteria
Shown below is the pretest probability of PE according to the modified Wells Criteria.[8][9][10][11]
Geneva Score
- The Geneva score is a clinical prediction rule used to determine the pre-test probability of pulmonary embolism based on the patient's risk factors and clinical findings.[12]
- The Geneva score has shown to be as accurate as the Wells score, but it is less reliant on the physicians clinical judgement.[13]
- The Geneva score has been revised and simplified from its original version, but it has been shown to have the same diagnostic utility as the original score.[14]
Original Geneva Score
Calculation of the Geneva Score
The original Geneva score is calculated using 7 risk factors and clinical variables:[12]
| Variable | Score |
| Age | |
| 60–79 years | 1.0 |
| ≥80 years | 2.0 |
| Previous venous thromboembolism | |
| History of prior DVT or PE | 2.0 |
| Previous surgery | |
| Recent surgery within 4 weeks | 3.0 |
| Heart rate | |
| Heart rate >100 beats per minute | 1.0 |
| PaCO2 (partial pressure of CO2 in arterial blood) | |
| <35 mmHg (<4.8 kPa) | 2.0 |
| 35-39 mmHg (4.8-5.19 kPa) | 1.0 |
| PaO2 (partial pressure of O2 in arterial blood) | |
| <49 mmHg (<6.5 kPa) | 4.0 |
| 49-59 mmHg (6.5-7.99 kPa) | 3.0 |
| 60-71 mmHg (8-9.49 kPa) | 2.0 |
| 72-82 mmHg (9.5-10.99 kPa) | 1.0 |
| Chest X-ray findings | |
| Band atelectasis | 1.0 |
| Elevation of hemidiaphragm | 1.0 |
Interpretation of the Geneva Score
Shown below is the interpretation of the Geneva score:[12]
- Score ≤ 4 points: low probability of PE (~10%)
- Score 5 to 8 points: moderate probability of PE (~38%)
- Score ≥ 9 points: high probability of PE (~81%)
Revised Geneva Score
Recently in 2006, the revised Geneva score was introduced with a more standarized and simplified algorithm to help predict the probability that a patient has a pulmonary embolism.[15]
Calculation of the Revised Geneva Score
Revised Geneva score calculator
| Variable | Score |
| Age more than 65 years | 1.0 |
| Prior history of DVT or PE | 3.0 |
| Surgery under general anesthesia or fracture of the lower limbs within the last month | 2.0 |
| Active malignant condition (currently active or cured less than 1 year ago) | 2.0 |
| Unilateral lower limb pain | 3.0 |
| Hemoptysis | 2.0 |
| Heart rate 75 to 94 beats per minute | 3.0 |
| Heart rate 95 or more beats per minute | 5.0 |
| Pain on deep palpation of lower limb and unilateral edema | 4.0 |
Interpretation of the Revised Geneva Score
- Score 0-3 points: lower probability of PE (8%)
- Score 4-10 points: intermediate probability of PE (28%)
- Score ≥ 11 points: higher probability of PE (74%)
Simplified Geneva Score
A one-point simplified scoring system replaced the previously weighted scores for each parameter. This was done to reduce the likelihood of error when the score is used in clinical settings. The simplified Geneva score does not lead to a decrease in diagnostic utility when compared to the previous Geneva scores.[14]
Calculation of the Simplified Geneva Score
Simplified Geneva Score calculator
| Variable | Score |
| Age >65 | 1.0 |
| Previous history of DVT or PE | 1.0 |
| Surgery under general anesthesia or fracture of the lower limbs within the last month | 1.0 |
| Active malignant condition (currently active or cured less than 1 year ago) | 1.0 |
| Unilateral lower limb pain | 1.0 |
| Hemoptysis | 1.0 |
| Heart rate 75 to 94 bpm | 1.0 |
| Heart rate greater than 94 bpm* | +1 |
| Pain on deep vein palpation of lower limb and unilateral edema | 1.0 |
| * Heart rates of 75 to 94 bpm receive 1 point, while heart rates higher than 94bpm receive a further point (i.e. 2 points in total) | |
Interpretation of the Simplified Geneva Score
Trichotomous Use of the Simplified Revised Geneva Score
- Score 0-1 points: low probability of PE (7.7%)
- Score 2-4 points: intermediate probability of PE (29.4%)
- Score ≥5 points: high probability of PE (64.3%)
Dichotomous Use of the Simplified Revised Geneva Score
PE Rule-Out Criteria (PERC)
- The Pulmonary Embolism Rule-out Criteria, or PERC rule, helps to evaluate patients in whom pulmonary embolism is suspected, but is unlikely.[16]
- Unlike the Wells Score and Geneva score, which are clinical prediction rules intended to risk stratify patients with suspected PE, the PERC rule is designed to rule out the risk of PE in low-risk patients stratified clinically by the physicians; hence, to prevent unnecessary diagnostic testing in this patient population.[17]
- In 2008, Kline et al, demonstrated that the PERC rule had a sensitivity of 97.4%, specificity of 21.9% and a false negative rate of 1.0% when used as a diagnostic test. The study further concluded that among patients with low suspicion for PE, a negative PERC rule reduced the probability of VTE to below 2% and in about 20% of outpatients with suspected PE.[18] On the similar lines, among the low pretest probability population, Wolf et al, demonstrated that the use of PERC-approach had a high negative predictive value and sensitivity, but a low positive predictive value and specificity.[17] On the contrary, among patients with a higher prevalence of PE (>20%), the PERC based approach has shown to have significantly poor predictive value.[19]
| Variables in PERC[16] |
| Age less than 50 years? |
| No hemoptysis? |
| No estrogen use? |
| No prior history of DVT or PE? |
| No unilateral leg swelling? |
| No surgery or trauma requiring hospitalization within the past four weeks? |
| Heart rate less than 100 bpm? |
| Oxyhemoglobin saturation ≥95 percent? |
Interpretation of PERC
If the answer to every question above is yes, then a pulmonary embolism can be ruled out according to the PERC rule.[16]
Pulmonary Embolism Severity Index (PESI) Score
The Pulmonary Embolism Severity Index (PESI) score aims to stratify patients with PE into classes of increasing rate of mortality and adverse outcomes.[20]
Calculation of PESI Score
| Age, per yr | Age, in yr |
| Male sex | 10 |
| Cancer | 30 |
| Heart failure | 10 |
| Chronic lung disease | 10 |
| Pulse ≥110 beat/min | 20 |
| Systolic blood pressure <100 mmHg | 30 |
| Respiratory rate ≥30/min | 20 |
| Temperature <36 | 20 |
| Altered mental status | 60 |
| Arterial oxygen saturation <90% | 20 |
Interpretation of PESI Score
| Class | Score | Class–specific 30-day mortality |
| Class I, very low risk | ≤65 | 1.1% |
| Class II, low risk | 65-85 | 3.1% |
| Class III, intermediate risk | 86-105 | 6.5% |
| Class IV, high risk | 106-125 | 10.4% |
| Class V, very high risk | >125 | 24.5% |
YEARS Algorithm
A comparison of the YEARS to the original Wells found that the YEARS is more sensitive, less specific, and a very similar Youden's J index or Gain in Certainty[21].
The YEARS algorithm uses the following three clinical variables:
- clinical signs of deep vein thrombosis (as swelling and edema)
- hemoptysis
- whether the physician considers PE to be "the most probable diagnosis."
The YEARS algorithm excludes PE in patients who either had:
- A d-dimer level less than 1,000 ng/mL and no clinical variables of YEARS
- OR
- d-dimer level less than 500 ng/mL and one or more YEARS items
A cluster-randomized, crossover comparison of the YEARS to a strategy of "all patients underwent D-dimer testing with the threshold set at the age-adjusted level" found similar clinical outcomes but less chest imaging with the YEARS algorithm[22].
Summary of PE Clinical Probability based on Clinical Prediction Rules
| Clinical Prediction Rules | Clinical Probability of PE | ||
| Low (%) | Moderate (%) | High (%) | |
| Empirical[12] | ~10 | ~33 | ~66 |
| Extended Wells Score[23][9][7] | 4 | 20 | 68 |
| Simplified Wells Score[23][8][24] | 15 | 29 | 59 |
| Original Geneva Score[12] | 10 | 38 | 81 |
| Revised Geneva Score[15] | 8 | 28 | 74 |
Based on pooled study data. Adapted from Recommendations of The PIOPED II Investigators.[25]
2008 Guidelines on the Diagnosis and Management of Acute Pulmonary Embolism- The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)(DO NOT EDIT)[26]
The clinical predictive scores of PE are important in the interpretation of the different diagnostic modalities used to diagnose the disease. The combination of the pre-test probability and the tests results helps in the inclusion/exclusion of PE.
Exclusion Criteria for PE
| Diagnostic Criteria | Clinical Probability of PE | ||
| Low | Intermediate | High | |
| Normal pulmonary angiogram | + | + | + |
| D-dimer: Negative result, highly sensitive assay | + | + | - |
| D-dimer: Negative result, moderately sensitive assay | + | - | - |
| V/Q Scan: Normal lung scan | + | + | + |
| V/Q Scan: Non-diagnostic lung scana | + | - | - |
| V/Q Scan: Non-diagnostic lung scana and negative proximal compression venous ultrasonography | + | + | ± |
| Chest CT: Normal single-detector CT and negative proximal compression venous ultrasonography | + | + | ± |
| Chest CT: Normal multi-detector CT alone | + | + | ± |
Confirmation of PE
| Diagnostic Criteria | Clinical Probability of PE | ||
| Low | Intermediate | High | |
| Pulmonary angiogram showing PE | + | + | + |
| High-probability V/Q Scan | ± | + | + |
| Compression venous ultrasonography showing proximal DVT | + | + | + |
| Chest CT: Single or multi-detector helical CT showing PE (at least segmental) | ± | + | + |
| Chest CT: Single or multi-detector helical CT showing sub-segmental PE | ± | ± | ± |
alow or intermediate probability lung scan according to the PIOPED classification
| + | Valid Criteria: No further testing required. |
| - | Invalid Criteria: Further testing necessary. |
| + | Controversial Criteria: Further testing to be considered. |
| “ |
Adapted from 2008 ESC guidelines on the diagnosis and management of acute pulmonary embolism. |
” |
References
- ↑ McGinn TG, Guyatt GH, Wyer PC, Naylor CD, Stiell IG, Richardson WS (2000). "Users' guides to the medical literature: XXII: how to use articles about clinical decision rules. Evidence-Based Medicine Working Group". JAMA : the Journal of the American Medical Association. 284 (1): 79–84. PMID 10872017. Retrieved 2012-04-26. Unknown parameter
|month=ignored (help) - ↑ Roy PM, Meyer G, Vielle B, Le Gall C, Verschuren F, Carpentier F, Leveau P, Furber A (2006). "Appropriateness of diagnostic management and outcomes of suspected pulmonary embolism". Ann. Intern. Med. 144 (3): 157–64. PMID 16461959.
- ↑ "Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED). The PIOPED Investigators". JAMA : the Journal of the American Medical Association. 263 (20): 2753–9. 1990. PMID 2332918.
|access-date=requires|url=(help) - ↑ Musset D, Parent F, Meyer G, Maître S, Girard P, Leroyer C, Revel MP, Carette MF, Laurent M, Charbonnier B, Laurent F, Mal H, Nonent M, Lancar R, Grenier P, Simonneau G (2002). "Diagnostic strategy for patients with suspected pulmonary embolism: a prospective multicentre outcome study". Lancet. 360 (9349): 1914–20. doi:10.1016/S0140-6736(02)11914-3. PMID 12493257. Retrieved 2012-04-26. Unknown parameter
|month=ignored (help) - ↑ Perrier A, Miron MJ, Desmarais S, de Moerloose P, Slosman D, Didier D, Unger PF, Junod A, Patenaude JV, Bounameaux H (2000). "Using clinical evaluation and [[lung]] scan to rule out suspected pulmonary embolism: Is it a valid option in patients with normal results of lower-limb venous compression ultrasonography?". Archives of Internal Medicine. 160 (4): 512–6. PMID 10695691. Retrieved 2012-04-26. Unknown parameter
|month=ignored (help); URL–wikilink conflict (help) - ↑ Wells PS, Hirsh J, Anderson DR, Lensing AW, Foster G, Kearon C, Weitz J, D'Ovidio R, Cogo A, Prandoni P (1995). "Accuracy of clinical assessment of deep-vein thrombosis". Lancet. 345 (8961): 1326–30. PMID 7752753. Unknown parameter
|month=ignored (help);|access-date=requires|url=(help) - ↑ 7.0 7.1 Wells PS, Ginsberg JS, Anderson DR, Kearon C, Gent M, Turpie AG, Bormanis J, Weitz J, Chamberlain M, Bowie D, Barnes D, Hirsh J (1998). "Use of a clinical model for safe management of patients with suspected pulmonary embolism". Ann Intern Med. 129 (12): 997–1005. PMID 9867786.
- ↑ 8.0 8.1 8.2 8.3 8.4 Wells P, Anderson D, Rodger M, Ginsberg J, Kearon C, Gent M, Turpie A, Bormanis J, Weitz J, Chamberlain M, Bowie D, Barnes D, Hirsh J (2000). "Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer". Thromb Haemost. 83 (3): 416–20. PMID 10744147.
- ↑ 9.0 9.1 9.2 9.3 Wells PS, Anderson DR, Rodger M, Stiell I, Dreyer JF, Barnes D, Forgie M, Kovacs G, Ward J, Kovacs MJ (2001). "Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer". Ann Intern Med. 135 (2): 98–107. PMID 11453709.
- ↑ 10.0 10.1 Stein PD, Woodard PK, Weg JG, Wakefield TW, Tapson VF, Sostman HD, Sos TA, Quinn DA, Leeper KV, Hull RD, Hales CA, Gottschalk A, Goodman LR, Fowler SE, Buckley JD (2007). "Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II Investigators". Radiology. 242 (1): 15–21. doi:10.1148/radiol.2421060971. PMID 17185658.
- ↑ van Belle A, Büller HR, Huisman MV, Huisman PM, Kaasjager K, Kamphuisen PW; et al. (2006). "Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography". JAMA. 295 (2): 172–9. doi:10.1001/jama.295.2.172. PMID 16403929.
- ↑ 12.0 12.1 12.2 12.3 12.4 Wicki J, Perneger TV, Junod AF, Bounameaux H, Perrier A (2001). "Assessing clinical probability of pulmonary embolism in the emergency ward: a simple score". Arch. Intern. Med. 161 (1): 92–7. PMID 11146703. Retrieved 2012-04-26. Unknown parameter
|month=ignored (help) - ↑ Iles S, Hodges AM, Darley JR, Frampton C, Epton M, Beckert LE, Town GI (2003). "Clinical experience and pre-test probability scores in the diagnosis of pulmonary embolism". QJM. 96 (3): 211–5. PMID 12615985. Retrieved 2012-04-26. Unknown parameter
|month=ignored (help) - ↑ 14.0 14.1 Klok FA, Mos IC, Nijkeuter M, Righini M, Perrier A, Le Gal G, Huisman MV (2008). "Simplification of the revised Geneva score for assessing clinical probability of pulmonary embolism". Arch. Intern. Med. 168 (19): 2131–6. doi:10.1001/archinte.168.19.2131. PMID 18955643. Retrieved 2012-04-26. Unknown parameter
|month=ignored (help) - ↑ 15.0 15.1 Le Gal G, Righini M, Roy PM, Sanchez O, Aujesky D, Bounameaux H, Perrier A (2006). "Prediction of pulmonary embolism in the emergency department: the revised Geneva score". Ann. Intern. Med. 144 (3): 165–71. PMID 16461960. Unknown parameter
|month=ignored (help);|access-date=requires|url=(help) - ↑ 16.0 16.1 16.2 Kline JA, Mitchell AM, Kabrhel C, Richman PB, Courtney DM (2004). "Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism". J Thromb Haemost. 2 (8): 1247–55. doi:10.1111/j.1538-7836.2004.00790.x. PMID 15304025.
- ↑ 17.0 17.1 Wolf SJ, McCubbin TR, Nordenholz KE, Naviaux NW, Haukoos JS (2008). "Assessment of the pulmonary embolism rule-out criteria rule for evaluation of suspected pulmonary embolism in the emergency department". The American Journal of Emergency Medicine. 26 (2): 181–5. doi:10.1016/j.ajem.2007.04.026. PMID 18272098. Retrieved 2012-04-30. Unknown parameter
|month=ignored (help) - ↑ Kline JA, Courtney DM, Kabrhel C, Moore CL, Smithline HA, Plewa MC, Richman PB, O'Neil BJ, Nordenholz K (2008). "Prospective multicenter evaluation of the pulmonary embolism rule-out criteria". J. Thromb. Haemost. 6 (5): 772–80. doi:10.1111/j.1538-7836.2008.02944.x. PMID 18318689. Retrieved 2012-04-26. Unknown parameter
|month=ignored (help) - ↑ Hugli O, Righini M, Le Gal G, Roy PM, Sanchez O, Verschuren F, Meyer G, Bounameaux H, Aujesky D (2011). "The pulmonary embolism rule-out criteria (PERC) rule does not safely exclude pulmonary embolism". J. Thromb.Haemost. 9 (2): 300–4. doi:10.1111/j.1538-7836.2010.04147.x. PMID 21091866. Retrieved 2011-12-19. Unknown parameter
|month=ignored (help) - ↑ Aujesky D, Obrosky DS, Stone RA, Auble TE, Perrier A, Cornuz J; et al. (2005). "Derivation and validation of a prognostic model for pulmonary embolism". Am J Respir Crit Care Med. 172 (8): 1041–6. doi:10.1164/rccm.200506-862OC. PMC 2718410. PMID 16020800.
- ↑ Abdelaal Ahmed Mahmoud M Alkhatip A, Donnelly M, Snyman L, Conroy P, Hamza MK, Murphy I; et al. (2020). "YEARS Algorithm Versus Wells' Score: Predictive Accuracies in Pulmonary Embolism Based on the Gold Standard CT Pulmonary Angiography". Crit Care Med. 48 (5): 704–708. doi:10.1097/CCM.0000000000004271. PMID 32079894 Check
|pmid=value (help). - ↑ Freund Y, Chauvin A, Jimenez S, Philippon AL, Curac S, Fémy F; et al. (2021). "Effect of a Diagnostic Strategy Using an Elevated and Age-Adjusted D-Dimer Threshold on Thromboembolic Events in Emergency Department Patients With Suspected Pulmonary Embolism: A Randomized Clinical Trial". JAMA. 326 (21): 2141–2149. doi:10.1001/jama.2021.20750. PMID 34874418 Check
|pmid=value (help). - ↑ 23.0 23.1 Sanson BJ, Lijmer JG, Mac Gillavry MR, Turkstra F, Prins MH, Büller HR (2000). "Comparison of a clinical probability estimate and two clinical models in patients with suspected pulmonary embolism. ANTELOPE-Study Group". Thrombosis and Haemostasis. 83 (2): 199–203. PMID 10739372. Retrieved 2012-04-30. Unknown parameter
|month=ignored (help) - ↑ Chagnon I, Bounameaux H, Aujesky D, Roy PM, Gourdier AL, Cornuz J, Perneger T, Perrier A (2002). "Comparison of two clinical prediction rules and implicit assessment among patients with suspected pulmonary embolism". The American Journal of Medicine. 113 (4): 269–75. PMID 12361811. Retrieved 2012-04-30. Unknown parameter
|month=ignored (help) - ↑ {{cite journal |author=Stein PD, Woodard PK, Weg JG, Wakefield TW, Tapson VF, Sostman HD, Sos TA, Quinn DA, Leeper KV, Hull RD, Hales CA, Gottschalk A, Goodman LR, Fowler SE, Buckley JD |title=Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II investigators |journal=[[The American Journal of Medicine|The American Journal of Medicine]] |volume=119 |issue=12 |pages=1048–55 |year=2006 |month=December |pmid=17145249 |doi=10.1016/j.amjmed.2006.05.060 |url=http://linkinghub.elsevier.com/retrieve/pii/S0002-9343(06)00779-0 |accessdate=2012-04-30}}
- ↑ Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P, Bengel F, Brady AJ, Ferreira D, Janssens U, Klepetko W, Mayer E, Remy-Jardin M, Bassand JP (2008). "Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)". Eur. Heart J. 29 (18): 2276–315. doi:10.1093/eurheartj/ehn310. PMID 18757870. Retrieved 2011-12-07. Unknown parameter
|month=ignored (help)
Categories:
- Pages with reference errors
- Pages with citations using unsupported parameters
- CS1 maint: Multiple names: authors list
- Pages using citations with accessdate and no URL
- CS1 errors: URL–wikilink conflict
- CS1 maint: Explicit use of et al.
- CS1 maint: PMC format
- CS1 errors: PMID
- Hematology
- Pulmonology
- Cardiology
- Emergency medicine
- Intensive care medicine